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Noree, T; (2015) The impact of medical tourism on the domestic economy and private health sys-tem: a case study of Thailand. PhD thesis, London School of Hygiene & Tropical Medicine. DOI:https://doi.org/10.17037/PUBS.02267963
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THE IMPACT OF MEDICAL TOURISM
ON THE DOMESTIC ECONOMY AND PRIVATE HEALTH SYSTEM: A CASE STUDY OF THAILAND
THINAKORN NOREE
Thesis submitted in accordance with the requirements for the degree of
Degree of Doctor of Philosophy of the University of London
June 2015
Department of Global Health and development
Faculty of Public Health and Policy
London School of Hygiene and Tropical Medicine
Funding detail: No funding was receive
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Declaration
I, Thinakorn Noree, confirm that the work presented in this thesis is my own. Where
information has been derived from other sources, I confirm that this has been
indicated in the thesis.
Signed: …………………………………..
Date: 15 June 2015
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Abstract
In the 21st century, medical tourism has emerged as a prosperous industry. Its growth
has been fostered by increasing healthcare costs, long waiting lists for non-
emergency operations and a lack of service availability in many developed countries.
This has resulted in a reverse phenomenon of patients travelling from developed
countries to developing ones to seek affordable healthcare and prompt services.
Developing countries in particular have established a variety of strategies to benefit
from this profitable market. However, the negative implications of the cross-border
movement of services have raised concerns. Quality of services and continuity of
care for patients are key concerns in source countries, and inequity, in terms of
access to services, rising healthcare costs and the ‘internal brain drain’ of healthcare
personnel are concerns in destination countries.
It is widely believed that there are substantial economic benefits to be gained from
medical tourism, but this belief is not based on a firm empirical foundation.
Similarly, there is a lack of empirical evidence concerning the impacts on the health
systems of destination countries. The divergence of views and overall lack of
evidence affords the potential for policy incoherence between trade and health. This
study intends to address this gap in the literature through an empirical assessment of
both medical tourism and the healthcare profiles of medical tourists. The overall aim
of the study is to assess the impact of medical tourism on the Thai economy and
domestic private health system. Thailand was selected as a appropriate country for a
case study due to its significant medical tourism industry. This study presents the
most extensive and detailed research on medical tourism and its effects on the private
health system to date, by drawing on 324,906 patient records in the five largest
private hospitals in the country.
The key findings are that medical tourists in Thailand are non-homogenous.
Comparisons present differences between them and non-medical tourists and Thai
private patients in terms of demography and service profiles. The majority are likely
to be opportunistic tourists, especially patients who use out-patient departments.
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Furthermore, the actual number of medical tourists is far fewer than is generally
suggested, although they and their companions contribute disproportionately to the
Thai economy in terms of medical and tourism-related spending. In terms of medical
services, there is no difference between the critical aspects of care given to Thai and
foreign patients. Hospitals make use of spare capacity to serve the demand of
foreigners. However, foreign patients might be partially responsible for a shortage of
high calibre doctors in public hospitals. Hence, if it wishes to continue with its
“Medical hub” policy, there is an evident need for the Thai government to consider
carefully the overall “cost” of this policy.
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Acknowledgements
First of all, I would like to thank my supervisor, Professor Richard Smith, and co-
supervisor, Dr Johanna Hanefeld, without whom I would never have become
involved in this challenging experience. I am infinitely grateful for their great
supervision, understanding, tireless support and many kind words of encouragement
during the course of my PhD study. I feel immensely fortunate to have had the
wonderful opportunity to work with and learn from them. Furthermore, I would also
like to thank Dr Stephen Pecham and Dr Dina Balabanova for their comments and
advice as my advisory committee. Finally, I would like to thank my viva examiners,
Professor David Hughes and Dr Jolene Skordis-Worrall, for their invaluable
comments and constructive discussion.
I also would like to thank Dr Phusit Prakongsai, Director of the International Health
Policy Program (IHPP) – Thailand, and Dr Viroj Tangcharoensathien, former
Director of IHPP, who always provided motivation, opportunities, and untiring
support. I am also indebted to Dr Mongkol Na Songkhla, former minister of the
Ministry of Public Health, Thailand, and Dr Suwit Wibulpolprasert not only for their
moral support, but also their connections with many private hospitals. These vital
connections made my impossible thesis become possible.
In my field work in private hospitals in Thailand, I am indebted to many hospital
executives and their administrative staffs. For Bumrungrad International Hospital, I
would like to thank Dr Chamaree Chuapetcharasopon, Dr Dwip Kitayaporm,
Natchayada Tanabvonnon and Kannika Klinhorm. For Bangkok Hospital, I would
like to thank Dr Chatree Duangnet, Dr Pravich Tanyasittisuntorn and Maneenait
Sopinnawat. For Bangkok Pattaya Hospital, I would like to thank Dr Pichit
Kangwolkij and Bunjerd Singhasorasri. For Bangkok Phuket Hospital, I would like
to thank Dr Narongrit Havarngsi, Dr Bodin La-ied and Mantaporn Thanapan. For
Samitivej Hospital, I would like to thank Dr Suthon Chutiniyomkarm and
Poramaporn Chunlaka. Information from these private hospitals contributed a
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substantial body of new knowledge for academic reference both domestically and
internationally. I also had positive experiences on ethical committees in these
hospitals. I learnt a lot about how to take care of patients and how to manage
hospitals from a private sector perspective. Moreover, I gratefully acknowledge the
help of the Director-General of the Department of Tourism, the Ministry of Tourism
and Sports, Thailand, for providing access to the database of the international tourist
survey. I would like to thank Uten Nunthasen, Research Supervisor of Excellent
Business Management Co.Ltd, for technical support in collecting data on tourism
expenditure.
I would like to thank my LSHTM friends who provided great experiences in living
and studying abroad in an academic environment. Special thanks are also given to Dr
Suriwan Thaiprayoon and Dr Warisa Panichkriengkrai who always provided
academic and emotional support during difficult situations. My thanks also go to
Susan Quarrell, Nurshen Reshat and Ela Gohil for their administrative support in the
school. Special thank is also given to Thidaporn Jirawattanapisal, my friend from
Queen Margaret University, who provided valuable information on human resources
for health in Thailand. Thanks, too, to my tireless proofreaders, Jenny Bardwell and
Frances Clark.
I gratefully acknowledge financial support from Human Resources for Health
Development program under International Health Policy Program, Thailand. I would
like to give special thanks to Sanya Srirattana and Naparat Utama for their
administrative support from Thailand during my study in LSHTM. Without this great
opportunity, it would not have been possible to pursue my dream and achieve my
goal.
Finally, I would like to thank my wife, Suthida Noree and my mother Srinoi Noree,
who have been patient and understanding of me at all times. I would like to thank my
brother, Wijane Noree, who has always supported me and provided a place for me to
stay in Paris when I needed some relaxation from hard studying. There are so many
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others I would like to acknowledge and I can only hope that they know that whilst I
cannot name them all, I am grateful to each and every one.
Thinakorn Noree
London
September 2014
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Table of content
Abstract ........................................................................................................................ 3
Acknowledgements ...................................................................................................... 5
Table of content ............................................................................................................ 8
Lists of Tables ............................................................................................................ 11
Lists of Figures ........................................................................................................... 15
Abbreviations ............................................................................................................. 16
Chapter 1 .................................................................................................................... 18
1.1 Medical tourism at the global level .................................................................. 20
1.2 The medical tourism industry in Thailand ....................................................... 21
1.3 The tourism industry in Thailand ..................................................................... 27
1.4 The Thai health system .................................................................................... 30
1.5 Conclusion ....................................................................................................... 34
1.6 Thesis outline ................................................................................................... 35
Chapter 2 .................................................................................................................... 38
2.1 Search methodology ......................................................................................... 38
2.2 What is medical tourism? ................................................................................. 39
2.3 Globalization of medical tourism ..................................................................... 40
2.4 Why do they travel? ......................................................................................... 44
2.5 Implications of medical tourism .................................................................. 46
2.6 Conclusion ....................................................................................................... 50
Chapter 3 .................................................................................................................... 53
3.1 Conceptual framework ..................................................................................... 53
3.2 Aim and objectives ........................................................................................... 57
3.3 Study design and research methodology .......................................................... 57
3.3.1 Specific research questions: ...................................................................... 59
3.3.2 Study areas ................................................................................................ 60
3.3.3 Terms and definitions ................................................................................ 63
3.3.4 Research methodology .............................................................................. 66
1) Sub-study 1: Assessing characteristics of medical tourists VS non-medical tourists and domestic patients ............................................................................ 66
2) Sub-study 2: Assessing the expenditures of medical tourists on medical care and tourism revenues ......................................................................................... 71
9
3) Sub-study 3: Assessing the impact of medical tourists on private hospitals 81
3.4 Ethical consideration ........................................................................................ 89
Chapter 4 .................................................................................................................... 92
4.1 Aim and specific research questions ................................................................ 93
4.2 Comparison between medical tourists and non-medical tourists ..................... 94
4.3 Comparison between medical tourists and Thai private patients ................... 102
4.4 Regional comparison of medical tourists ....................................................... 114
4.5 Discussion and conclusion ............................................................................. 129
Chapter 5 .................................................................................................................. 136
5.1 Aim and specific research questions .............................................................. 138
5.2 Tourism behaviours of medical tourists ......................................................... 139
5.3 Tourism expenditure ....................................................................................... 145
5.3.1 Tourism expenditures of medical tourists, their companions, and non-medical tourists. ............................................................................................... 145
5.3.2 Tourism spending profiles ....................................................................... 153
5.3.3 Influencing factors on actual tourism expenditure .................................. 160
5.4 Medical expenditure ....................................................................................... 162
5.4.1Comparison between medical tourists and Thai private patients ............. 162
5.4.2 Medical expenditure: Regional comparison............................................ 173
5.5 Discussion and conclusion ............................................................................. 178
Chapter 6 .................................................................................................................. 186
6.1 Aim and specific research questions .............................................................. 188
6.2 Difference in service use between international and Thai patients ................ 188
6.2.1 Service provision between domestic and foreign patients ...................... 188
6.2.2 Price ........................................................................................................ 193
6.2.3 Resource allocation ................................................................................. 195
6.3 Resources for international patients ............................................................... 197
6.3.1 Infrastructures and medical devices ........................................................ 197
6.3.2 Human resources for health .................................................................... 199
6.4 Revenue allocation ......................................................................................... 204
6.5 Discussion and conclusion ............................................................................. 208
Chapter 7: ................................................................................................................. 215
7.1 Discussion ...................................................................................................... 217
7.2 Limitations of the study ............................................................................. 232
7.3 Conclusion ..................................................................................................... 235
7.4 Recommendations .......................................................................................... 237
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7.4.1 Policy recommendations ......................................................................... 237
7.4.2 Recommendations for research priorities ................................................ 239
References ................................................................................................................ 242
Annexes .................................................................................................................... 253
Annex 1: Ethical committee approval .................................................................. 254
Annex 2: Information sheet and consent form for patient survey ........................ 255
Annex 3: Questionnaire for patient survey (in English, Arabic and Japanese) .... 261
Annex 4: Information sheet and consent form for interview (hospital executives and service providers) .......................................................................................... 271
Annex 5: Semi-structured questions for interview............................................... 278
Annex 6: List of interview participants ................................................................ 280
Annex 7: Country comparison on characteristic of medical tourists ................... 282
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Lists of Tables
Chapter One
Table 1.1: International patients in private hospitals ............................................................. 25
Table 1.2: Thai health care infrastructures in 2009: Pluralistic nature .................................. 31
Table 1.3: Distribution of main cadres of HRH by region, 2000 ........................................... 33
Chapter Two
Table 2.1: Comparative cost of medical procedure by country ............................................. 45
Chapter Three
Table 3.1: Hospital ranking by international patient services in 2007 ................................. 61
Table 3.2: Number of medical tourists by region .................................................................. 69
Table 3.3: Data sources .......................................................................................................... 72
Table 3.4: Sample distribution ............................................................................................... 75
Table 3.5: Key variables on tourism expenditures ................................................................. 78
Table 3.6: Explanation of each factor employed in a spending function ............................... 80
Table 3.7: Core information and key informants ................................................................... 85
Table 3.8: Participant code .................................................................................................... 89
Chapter Four
Table 4.1: Number of international patients and visits by type of patient ............................. 95
Table 4.2: Regional distribution between medical tourists and non-medical tourists ........... 96
Table 4.3: Countries of origin of medical tourists compared to those of non-medical tourists
............................................................................................................................................... 98
Table 4.4: Gender comparison between medical tourists and non-medical tourists ............ 100
Table 4.5: Comparison of gender between medical and non-medical tourists .................... 100
Table 4.6: Age distribution between medical tourists and non-medical tourists ................ 101
Table 4.7: Number of patients and visits in the five hospitals in 2010, by types of patients
............................................................................................................................................. 103
Table 4.8: Gender comparison between medical tourists and Thai private patients ............ 103
Table 4.9: Age distribution between medical tourists and Thai private patients ................. 104
Table 4.10: Average age of medical tourists and Thai private patients .............................. 104
Table 4.11: Disease patterns among male medical tourists and male Thai private patients 106
Table 4.12: Disease patterns among female medical tourists and female Thai private patients
............................................................................................................................................. 107
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Table 4.13: Procedures in male medical tourists and male Thai private patients ................ 109
Table 4.14: Procedures in female medical tourists and female Thai private patients .......... 110
Table 4.15: Length of stay of medical tourists and Thai private patients ............................ 112
Table 4.16: Average length of stay of medical tourists and Thai private patients .............. 112
Table 4.17: Types of payment of medical tourists and Thai private patients ...................... 113
Table 4.18: Number of patients and visits of medical tourists by region ............................. 114
Table 4.19: Gender distribution of medical tourists by region ............................................ 115
Table 4.20: Age distribution of medical tourists by regions ................................................ 116
Table 4.21: Average age of medical tourists by region ....................................................... 116
Table 4.22: Disease patterns in male medical tourists by region ........................................ 118
Table 4.23: Disease patterns in female medical tourists by region ..................................... 120
Table 4.24: Number of procedures among medical tourists in the five private hospitals, in
2010, by region .................................................................................................................... 121
Table 4.25: Type of procedure in male medical tourists by regions .................................... 123
Table 4.26: Type of procedure in female medical tourists by region .................................. 125
Table 4.27: Length of stay of medical tourists by region ................................................... 126
Table 4.28: Average length of stay of medical tourists by region ...................................... 126
Table 4.29: Type of payment by medical tourist by region ................................................ 127
Chapter Five
Table 5.1: Region and country of origin of participants ...................................................... 139
Table 5.2: Gender of participants by region ........................................................................ 140
Table 5.3: Age group of participants by region ................................................................... 140
Table 5.4: Average age of participants by region ................................................................ 140
Table 5.5: Occupation of participants by region .................................................................. 141
Table 5.6: Income of participants by region ........................................................................ 141
Table 5.7: Level of importance of medical service for visit ................................................ 142
Table 5.8: History of medical services in Thailand by region ............................................. 143
Table 5.9: Type of medical service preparation by region ................................................... 143
Table 5.10: Length of stay of participants by region ........................................................... 144
Table 5.11: Average length of stay of participants by region .............................................. 144
Table 5.12: Number of companions by regions ................................................................... 144
Table 5.13: Revenue from international tourists visiting Thailand from 2007-2012 ........... 145
Table 5.14: Tourism expenditure of non-medical tourists, medical tourists and companions
............................................................................................................................................. 146
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Table 5.15: Average tourism expenditure of non-medical tourists, medical tourists and
companions .......................................................................................................................... 146
Table 5.16: Tourism expenditure between non-medical tourists, medical tourists and
companion by regions .......................................................................................................... 148
Table 5.17: Average tourism expenditure between non-medical tourists, medical tourists and
companions by region .......................................................................................................... 149
Table 5.18: Tourism expenditure of non-medical and medical tourists, by gender ............. 151
Table 5.19: Average tourism expenditure between non-medical tourists and medical tourists
by gender .............................................................................................................................. 152
Table 5.20: Tourism spending profiles per tourism day by non-medical tourists, medical
tourists and companions ....................................................................................................... 155
Table 5.21: Tourism spending profiles per tourism day by non-medical tourists, medical
tourists and companions, by region...................................................................................... 156
Table 5.22: Tourism spending profiles per tourism day by non-medical tourists and medical
tourists by gender ................................................................................................................. 157
Table 5.23: Comparison of expenditure by non-medical tourists and medical tourists, by
tourism spending item .......................................................................................................... 158
Table 5.24: Comparison of expenditure by non-medical tourists and medical tourist’s
companions, by tourism item ............................................................................................... 159
Table 5.25: Influencing factors on tourism expenditure ...................................................... 161
Table 5.26: Medical expenditure by medical tourists and Thai private patients ................. 163
Table 5.27: Average medical expenditure by medical tourists and Thai private patients .... 163
Table 5.28: Total revenue by type of patient in the five hospitals in 2010 .......................... 163
Table 5.29: Medical expenditure by medical tourists and Thai private patients by gender . 165
Table 5.30: Average medical expenditure by medical tourists and Thai private patients, by
gender ................................................................................................................................... 166
Table 5.31: Out-patient expenditure by medical tourists and Thai private patients, by age
group .................................................................................................................................... 168
Table 5.32: Average out-patient expenditure by medical tourists and Thai private patients, by
age group .............................................................................................................................. 169
Table 5.33: In-patient expenditure by medical tourists and Thai private patients, by age
group .................................................................................................................................... 170
Table 5.34: Average in-patient expenditure by medical tourists and Thai private patients, by
age group .............................................................................................................................. 171
Table 5.35: Comparison of medical expenditure by medical tourists and Thai private patients
............................................................................................................................................. 172
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Table 5.36: Comparison of medical expenditure by medical tourists, by gender ................ 172
Table 5.37: Medical expenditure of medical tourists, by regions ........................................ 174
Table 5.38: Average medical expenditure of medical tourists, by region ............................ 174
Table 5.39: Medical expenditure of medical tourists between regions, by gender .............. 175
Table 5.40: Average medical expenditure of medical tourists between regions, by gender 175
Table 5.41: Medical expenditure of medical tourists between regions by age groups ........ 176
Table 5.42: Comparison of medical expenditures of medical tourists, by regions .............. 177
Chapter Six
Table 6.1: Number of physicians in BDMS ......................................................................... 202
Table 6.2: Number of nurses in BDMS ............................................................................... 202
Table 6.3: Revenue and expenditure of Bumrungrad Hospital ............................................ 207
Table 6.4: Revenue and expenditure of Bangkok Dusit Medical Services (BDMS) ........... 207
15
Lists of Figures Chapter One
Figure 1.1: Type of international patients .............................................................................. 26
Figure 1.2: Type of medical services ..................................................................................... 26
Figure 1.3: Number of international tourists in Thailand between 2000 and 2012 ............... 28
Figure 1.4: International tourists by region in 2005 ............................................................... 29
Figure 1.5: International tourists by region in 2010 ............................................................... 29
Figure 1.6: Revenues from international tourists by region in 2005 ...................................... 30
Figure 1.7: Revenues from international tourists by region in 2010 ...................................... 30
Figure 1.8: Private hospitals by number of beds in 2009 ....................................................... 32
Chapter Three
Figure 3.1: Conceptual model on impact of international patients ........................................ 56
Figure 3.2: Location of the five targeted private hospitals in the study ................................. 62
Figure 3.3: Overall framework of the research design .......................................................... 65
Figure 3.4: Cascade of participants in four private hospitals ................................................. 86
Chapter Six
Figure 6.1: Revenue contribution by nationality in Bumrungrad hospital ........................... 205
Figure 6.2: Revenue contribution by nationality in Bangkok Dusit Medical Service ......... 205
Chapter Seven
Figure 7.1: International patients by categories in each hospital ......................................... 220
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Abbreviations
AEC ASEAN Economic Community
AMA The American Medical Association
AMA-OMSS The American Medical Association – Organized Medical staff Section
ASEAN Association of Southeast Asian Nations
BDMS Bangkok Dusit Medical Service Public Company Limited
BMA Bangkok Metropolitan Administration
BAPRAS The British Association of Plastic, Reconstructive and Aesthetic
Surgeons
CEOs Chief executive officers
DEP Department of Export Promotion
GDP Gross domestic product
HRH Human resources for health
ICD-10 Tenth revision of the International Classification of Diseases and
Related Health Problems (ICD-10)
ICD-9 CM Ninth revision of the International Classification of Disease, Clinical
Modification
IP In-patient
JCI Joint Commission International
LSHTM London School of Hygiene and Tropical Medicine
MOC Ministry of Commerce
MOPH Ministry of Public Health
MOTS Ministry of Tourism and Sports
NGO Non-government organization
OP Out-patient
TAT The Tourism Authority of Thailand
TEIM The travel economic impact model
THB Thai Baht
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Chapter One
Introduction
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Chapter 1 Introduction
Tourism is the world's largest industry and it is considered of vital importance to the
global economy [1]. Its contribution has risen dramatically over recent decades [2].
In 2012, international tourist arrival was 1,035 million, representing a growth of 4%
from 2011 [3]. The industry is highly fragmented, being made up of a large number
of small businesses. Considerable numbers of people travel domestically and
internationally and spend money with many businesses, from transportation to local
businesses in the destination areas. This creates significant employment at all levels,
from highly skilled managers in world-class hotels to employees in small souvenir
shops.
Travel for health and wellness care has a long history, beginning in the 19th century.
Wealthy patients from less developed countries travelled in search of the advanced
care available in western countries. However, in the 21st century, a new type of
tourism – medical tourism – emerged [4]. This phenomenon refers to people
travelling outside their home countries, specifically for health care, usually
specialized, and typically delivered in hospital. This development represents not only
a change of reason for a great deal of travel, but that it is also no longer the preserve
of the rich [5]. It is increasing significantly throughout the world, particularly in
developing countries [6]. Increasing costs of healthcare, long waiting lists for non-
emergency operations and a lack of service availability in many developed countries,
together with cheaper travel and borderless communication through the internet, are
major factors in fostering the growth of medical tourism [7]. This is resulting in a
reverse phenomenon of patients travelling from developed to developing countries to
seek affordable healthcare and prompt service [8]. Medical tourism as a term is still
ambiguously defined. However, it is widely accepted that it relates to health services;
for example, medical check-ups, dental care and elective procedures. Wellness
tourism, such as spas, traditional therapy and homeopathic therapy, is generally
excluded.
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The growth and importance of tourism as a global industry has led many countries to
identify medical tourism as a potentially important national industry [9], and they
have developed various means to capitalize on it, including the presentation of
international road-shows advertising a country as a desirable destination, and tax
exemption schemes to encourage investment in facilities to service these medical
tourists. Many private hospitals have also improved their capacity by using advanced
medical devices and state-of-the-art techniques, conducted by highly skilled
professionals, in the same way as those employed in world-famous medical institutes
in the US and Europe.
Thailand is the foremost destination country for medical tourists in Southeast Asia
[10]. Besides its reputation as a tourist destination, the relatively competitive prices;
the high quality of services, accredited by the Joint Commission International; and
excellent hospitality, are the main contributing factors. Government policy first
emphasized medical tourism in 2003 through the “Thailand: Centre of Excellent
Health Care of Asia” initiative, designed to attract international patients, with the
collaboration of the Ministry of Commerce, the Ministry of Public Health, the
Ministry of Tourism and Sports, the Ministry of Foreign Affairs and the Private
Hospital Association. To promote the medical tourism industry, many strategies were
initiated including international marketing, the improvement of domestic health
facilities to international standards, and tax exemptions for local and foreign
investors investing in new health facilities for serving foreigners. The policy was
perceived as successful, making Thailand the largest service provider for medical
tourists in the world, and led to a second phase of the policy, originally planned for
launch in 2013 but so far not implemented, to maintain the growth of this industry.
Based on a Thai Ministry of Commerce survey conducted in 2007, private hospitals
have by far the major role in serving this industry, with 99% of medical tourists
treated in the private rather than the public sector.
Over the last decade there has been a sustained increase in foreign patients in
Thailand, and this trend is still continuing [10]. There is an expectation that it will
lead to substantial financial benefit and a boost to the economy. The Thai
government was expecting an income of 1 billion USD in 2008 from these lucrative
20
patients. However, many concerns were expressed about its implications for the
domestic health system, such as the likelihood of crowding-out local patients, and
contributing to a two-tier health system. Much international and domestic literature
discusses these controversial issues [11, 12], but there remains a lack of empirical
evidence. There has been only one study, which concludes that MT makes a small
contribution to the overall economy [10] and there is no empirical evidence for any
effects on the Thai health system. This study, therefore, investigates the implications
of MT for both the domestic economy and the Thai health system, with a specific
focus on private hospitals, as this is where 99% of medical tourism takes place. It
provides the most extensive and detailed research on medical tourism and its effects
on the Thai health system to date, by drawing on 324,906 patient records in the five
largest private hospitals in the country.
This chapter introduces the thesis by providing an overview of medical tourism at
both the global level and in Thailand. An overview of the Thai health system is also
provided, and the rest of the thesis outlined.
1.1 Medical tourism at the global level
The number of patients travelling for health care abroad has continually increased
during the past few decades. This type of cross-border service has become a new
type of health industry, but the actual number of medical tourists is still difficult to
identify. However, it is estimated that the industry generates approximately 60 billion
USD per year with a growth rate of 20% per year [13].
Patients mostly come from North America, Western Europe and the Middle East. In
2007, it was estimated that approximately 750,000 American patients travelled
abroad for healthcare [14]. The main destinations were in Asia, Eastern Europe, the
Caribbean and South America. The key push factors in the source countries are the
high cost of care, long waiting lists for elective procedures and unavailable or poor
quality services. Meanwhile, international standards of service, competitive prices
and prompt service are key pull factors in destination countries. Moreover, cheaper
long-haul transportation, an increase in the effectiveness of the internet and an
21
emergence of medical brokerage encourage the growth of the medical tourism
industry.
However, despite this growth the implications of medical tourism remain
inadequately assessed. Most literature is based on assumptions and opinion rather
than empirical evidence. However, it is widely accepted that medical tourism is
likely to create substantial increases to a country’s revenues, but will also have an
undesirable impact on the domestic health system, such as increasing the
development of a two-tier health system and aggravating doctor shortages in the
public sector [6, 15, 16]. There is no strong evidence base supporting this wide
acknowledgement, however.
1.2 The medical tourism industry in Thailand
Thailand is the largest medical tourism market in Asia. In 2006, there were estimated
to be 1.2 million international patients entering the country for health services,
generating approximately US$ 1.1 billion in revenue; approximately 9% of the total
revenue from tourism overall, and 0.53% of overall GDP [4].
The turning point pushing Thailand into a flourishing medical tourism market came
after the economic crisis in 1997. During the economic boom era, from 1991, the
increase in the personal income of Thai nationals resulted in increased demand for
high quality health services, particularly in the private sector. Many leading private
hospitals expanded their capacity in order to cope with this increased demand. The
proportion of beds in private hospitals increased from 10.6% in 1989 to 22.6% in
1997 [17]. After the economic crisis in 1997, domestic consumption of private health
services declined considerably and many private hospitals closed down between
1998 and 2003 [17]. Some found new markets to compensate for this loss;
principally marketing services to patients from abroad. This approach resulted in
470,000 international patients in 2001, an increase of 38% on the previous year [18].
In 2003, though the crisis in private hospitals had been relieved, the Thaksin
government tried to push Thailand to be a centre of healthcare in the region by
22
attracting foreign patients in order to increase national revenues. The policy
“Thailand: Centre of Excellent Health Care of Asia” was launched. This policy
focused on three main products; medical services, health promotion services and
herbal products [19]. Well-organized coordination among public and private agencies
was established. There was collaboration between the Ministry of Public Health, the
Ministry of Commerce, the Ministry of Tourism and Sports and the Ministry of
Foreign Affairs. Many strategies were used, such as an international road show and
tax exemptions for investment in new international health facilities [20]. However,
the private sector remains the main driving mechanism to achieve the targets [10]. At
the end of this first phase, the Department of Export Promotion and the Ministry of
Commerce deemed the policy a success, as there were more than 1.2 international
patients annually and Thailand had become the foremost country in this market.
During 2004-2008, the industry generated US$ 7.5 billion, 60% more than was
expected [21].
During the political instability after the coup d’état in 2006, there was no apparent
movement on this policy during 2007-2009 [22]. In 2010, the Ministry of Public
Health planned to announce the second phase of the “Thailand Medical Hub” policy,
planned for the period between 2010 and 2014. However, there was concern in the
wider Thai society about the negative implications of this policy, such as an internal
brain drain of doctors and the possibility of generating a two-tier health system. This
issue was placed into the third forum of the Thai National Health assembly in 2010.
This is a public forum, convened once a year, to develop participatory public health
policies. The second phase of the “Thailand Medical Hub” policy was then deferred
to reconsider these possible undesirable impacts and how to mitigate them [23].
In 2012, the new government of Prime Minister Yinglak pursued the second phase of
the “Thailand Medical Hub” policy again. In this period, the scope of this policy
was extended beyond health service arena. The new “Thailand Medical Hub”
expanded to 1) The Wellness Hub – including health promotion service and spas, 2)
The Medical Service Hub – serving foreign patients, 3) The Academic Hub –
including research centres in the health arena and 4) The Product Hub – including
drugs and other health products [19]. This movement included medical schools as
23
major stake-holders in order to establish the Academic Hub. The strategic plan for
the second phase of the “Thailand Medical Hub” between 2014 and 2018 is being
revised by multi-stake holders to ensure that concerns over undesirable implications
are taken into account before government approval [22].
The new phase aims to push Thailand to the status of a world class healthcare
provider and a sophisticated academic hub. General patients, specialized care, dental
procedures and services for older people are the main foci for medical services. It is
also encouraging public hospitals to develop international standards of care to service
both domestic and foreign customers. Total revenues of 814 billion THB (27 billion
USD) are estimated to result from this policy during the period 2014-2018 [19].
Competitive advantage of Thailand
Thailand, India and Singapore are well-known as medical tourism destinations in
Southeast Asia, accounting for an estimated 90% of the medical tourism industry in
the region [10]. It is estimated that in 2008 there were 1.36 million international
patients in Thailand (Table 1.1). The Asian Trends Monitoring Bulletin reported that
in 2007 there were an estimated 341,288 international patients in Malaysia and
348,000 international patients in Singapore, producing revenues of 0.78 billion USD
and 1.2 billion USD respectively [24]. The competitive prices, high quality of
services and impressive hospitality of many tourist attractions are seen as key
elements of success for Thailand [25]. Medical care in Thailand costs more than in
India, but less than in Singapore. Local currency devaluation after the economic
crisis, as well as low labour costs, make the price of medical treatment in Thailand
attractive. For some kinds of heart operation, such as a heart bypass, the Thai price is
90% cheaper than that in the US [26]. Thailand also has good health infrastructures:
many private hospitals provide highly-specialized tertiary care at international
standards. Currently, 22 private hospitals are accredited by the Joint Commission
International (JCI), the global hospital accreditation organization. These hospitals
utilize sophisticated, state-of-the-art medical equipment. Many Thai doctors serving
there have been trained in the US, the UK, and other European countries. The high
quality of Thai medical service is another factor in attracting foreign patients. Thai
24
hospitality is also unique and distinguishes the country from others. Moreover,
Thailand is a well-known tourist destination. A warm climate, a variety of tourist
attractions from coasts to tropical forests, and good sanitation are key contributing
factors, whereas Singapore is a small island with a limited number of tourist
destinations, and India still has sanitation problems.
Increasing demand by overseas patients
Expensive health care, long waiting lists and unavailable services are key
contributing factors that drive patients to seek healthcare abroad [27]. Patients in
western countries, especially the US, have faced high-cost medical care for many
years, and may have no insurance, making access to domestic health services
prohibitively expensive. Overall expenses, including travelling costs and
accommodation are often cheaper in other countries. Patients from Canada, the
United Kingdom and other European countries may not face high healthcare costs,
but do face long waiting lists for treatment, particularly elective procedures, under
their national health insurance schemes. Patients from the Middle East and some
countries in Southeast Asia, such as Myanmar and Cambodia, seek services abroad
which are unavailable in their own countries, such as heart-related and orthopaedic
procedures.
Current information on medical tourists
The Department of Export Promotion, Ministry of Commerce (DEP, MOC),
estimated that in 2003 there were 973,532 international patients generating US$ 660
million in revenues. With the continuous growth in numbers of these patients, there
were an estimated 1.36 million foreign patients in Thailand in 2008 (Table 1).
However, most of their treatment was delivered in private hospitals. The public
sector has taken very little part in this industry. Data from the MOTS survey in 2008
showed that the majority of international patients were in private hospitals, and only
0.9% of them were in public hospitals; mostly university hospitals. Patients from
Japan, the USA, UK, Middle East and ASEAN are key market share. Expatriates are
the main component of the international patients in Thailand, while medical tourists
25
coming specifically for medical services constitute 27% (Figure 1.1). The most
popular services for these medical tourists are orthopaedic procedures, cardiac
surgery, physical examination, cosmetic surgery, gastrointestinal diseases and dental
care (Figure 1.2).
Table 1.1: International patients in private hospitals
Country of origin
Number of patients
2002 2003 2004 2005 2008 2011 2012
1 Japan 131,584 162,909 247,238 185,616 200,642 177,058 182,807
2 USA 59,402 85,292 118,771 132,239 114,872 74,058 76,277
3 South Asia 47,555 69,574 107,627 98,308 73,991 52,004 61,999
4 UK 41,599 74,856 95,941 108,156 91,969 63,937 62,448
5 Middle East 20,004 34,704 71,051 98,451 164,943 91,117 98,657
6 ASEAN N/A 36,708 93,516 74,178 139,887 122,404 113,522
7 Taiwan/China 27,438 46,624 57,051 57,279 33,492 32,310 48,396
8 Germany 18,923 37,055 40,180 42,798 38,730 32,310 28,716
9 Australia 16,479 24,228 35,092 40,161 35,998 24,915 42,831
10 France 17,679 25,582 32,409 36,175 31,000 34,519 35,472
11 South Korea 14,877 19,588 31,303 26,571 21,999 17,262 19,594
12 Scandinavia N/A 19,851 20,990 22,921 N/A N/A N/A
13 Canada N/A 12,909 18,144 18,177 18,750 12,784 14,109
14 East Europe N/A 8,634 6,728 6,120 12,782 7,841 9,947
15 others 234,460 315,018 127,054 302,834 384,240 192,516 147,379
Total 630,000 973,532 1,103,095 1,249,984 1,363,295 934,587 954,107
Source: Department of Export Promotion, Ministry of Commerce
Note: Number of international patients after 2008 shows a decline, as not all hospitals responded to
this survey.
26
Figure 1.1: Type of international patients
Source: Department of Export Promotion Ministry of Commerce
Figure 1.2: Type of medical services
Source: Department of Export Promotion Ministry of Commerce
Bumrungrad International Hospital has progressed forcefully in this market [28]. In
2005, the hospital welcomed around 150,000 overseas patients, 55,000 of whom
were from the US [29]. At present, international patients account for 50% of their
total clientele [29].
Although the number of international patients has increased in recent year, it remains
very small compared to the number of domestic patients. The National Statistical
Office reported that in 2011, 46 million patients were treated in private hospitals
[30], while 136 million patients were treated in public hospitals [31]. According to
Expatriates, 41
Tourists, 32
Medical travellers, 27
Orthopaedics, 22
Cardiac surgery, 19
Physical examination and
others, 17
Cosmetic surgery, 16
Gasatrointestinal procedures, 13
Dental care, 13
27
this estimate, international patients represent approximately 2.8% of the total number
of private patients, and 0.9% of the total number of all patients, in Thailand.
Domestic economic impact
It is widely believed that the medical tourism industry contributes to the Thai
economy, but how much it contributes remains unclear. The Department of Export
Promotion, the Ministry of Commerce estimated that international patients
contributed some 3.5 billion USD in 2008 [21]. Based on the international patient
survey by DEP, from the MOC, Na Ranong et al (2011) forecast that medical tourists
contribute some 1.9-2.1 billion USD from medical services and related tourism [10].
1.3 The tourism industry in Thailand
Thailand is famous for impressive historical sites, rich and vibrant cultures, beautiful
beaches, scenic countryside, and gentle, polite and genuinely friendly people [32].
The country has had a long experience in the tourism industry, and tourists from all
over the world know Thailand as the “Land of Smiles”.
The tourism industry is important to Thailand [33]. According to World Tourism
Organization data, in 2012, 20.7 million overseas travellers visited Thailand, an
increase of 16.2% compared to the previous year. Thailand is ranked 4th in terms of
the size of its tourist sector amongst Asian and Pacific countries [1]. The industry
has grown continuously since 1960, after the Tourism Authority of Thailand (TAT)
was established as having specific responsibility for the promotion of tourism, the
importance of which was realized and established in the first National Economic and
Social Development plan in 1961 [34]. Since 1960, Thailand has seen the annual
number of international tourists increase from 81,340 to over 20 million. After the
economic crisis in 1997, the tourism industry was one of the key factors which drove
the domestic economic recovery. The campaign “Amazing Thailand” was launched
between 1998 and 1999.
28
Many factors affect the tourism industry. At the global level, increases in the overall
number of international travellers around the world directly have enhanced the
number of tourists in Thailand, while the financial crisis in The US and Europe in
2009 resulted in a reduction of the overall numbers of international travellers around
the world. Meanwhile, internal factors, such as the tsunami of 2004, political
instability in 2009-2010, and a serious flood in 2011, directly affected the number of
tourists. However, to date there has always been a strong rebound from such events
(Figure 1.3).
Figure 1.3: Number of international tourists in Thailand between 2000 and 2012
Source: Department of Tourism, MOTS
Tourists from within the local region have dominated, accounting for 62% in 2005
and 2010 (Figure 1.4 and 1.5). Tourists from ASEAN have become more important.
Tourists from East Asia were the largest group in 2005, accounting for almost 30%,
while tourists from ASEAN took over as the largest group in 2010, accounting for
28.8%. Tourists from Europe were still the largest group of those from long-haul
origins, accounting for 27% in 2010 (Figure 1.5). Moreover, tourists from ASEAN
will become more important after the starting of ASEAN Economic Community
(AEC) in 2015 which will enable people in the region to move freely across borders
(similarly to EU practice). It is expected that Thailand will benefit, given its location
in the centre of the region. In 2011, the top ten countries of origin of tourists arriving
in Thailand were Malaysia, China, Japan, Russia, South Korea, India, Laos,
Australia, the UK and the USA.
0
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
2000 2002 2004 2006 2008 2010 2012
29
Figure 1.4: International tourists by region in 2005
Source: Department of Tourism, MOTS Figure 1.5: International tourists by region in 2010
Source: Department of Tourism, MOTS
The continuous expansion of revenue has significantly contributed to the Thai
economy, accounting for 5.8% of GDP in 2009 [35]. Revenues from international
tourists have continuously increased from 367 billion THB (12.2 billion USD) in
2005 to 585 billion THB (19.5 billion USD) – an approximately 60% increase in five
year. Tourists from Europe were key contributors; approximately 37% and 40% of
total revenues from international tourism in 2005 and 2010 respectively (Figure 1.6
and 1.7).
ASEAN, 25.6
East Asia, 29.94
Europe, 24.7
America, 7.23
South Asia, 4.71
Ocenia, 4.48
Middle East, 2.54 Africa, 0.74
ASEAN, 28.84
East Asia, 23.27
Europe, 27.17
America, 4.97
South Asia, 6.18
Ocenia, 4.95
Middle East, 3.86 Africa, 0.76
30
Figure 1.6: Revenues from international tourists by region in 2005
Source: Department of Tourism, MOTS Figure 1.7: Revenues from international tourists by region in 2010
Source: Department of Tourism, MOTS
1.4 The Thai health system
The Thai health system is pluralistic and dominated by the public sector. Thai people
depend increasingly on health-facility based services. The percentage using facility-
based health services has increased from 38.5% in 1970 to 72.5 % in 2006 [36].
Annual health expenditure rose from 4.47% of gross domestic product (GDP) in
1983 to 6.4% in 2008 [17]. There was also a trend toward increased public spending
from 31.5% in 1983 to 42.7% in 2008 [17]. The Ministry of Public Health [37]
ASEAN, 12.56
East Asia, 30.24
Europe, 37.32
America, 8.87
South Asia, 3
Ocenia, 4.52
Middle East, 3
Africa, 0.45
ASEAN, 16.45
East Asia, 18.62
Europe, 39.67
America, 7.73
South Asia, 4.77
Ocenia, 7.20
Middle East, 4.69 Africa, 0.87
31
covers around two thirds of the public spending on health. In the past, 75% of Thais
were insured under various health insurance schemes. The former government started
to implement universal coverage of healthcare (30 Baht Scheme) in 2001, and
currently more than 95% of Thais are covered by health insurance [38].
1.4.1 Public health facilities
Structurally, the Ministry of Public Health [37] is the main national health agency. It
owns the majority of health resources, particularly in rural areas (Table 2). In 2009,
the MOPH has four general hospitals in Bangkok, 25 regional hospitals and 69
general hospitals at provincial level (Table 2), all providing tertiary medical care. All
hospitals at the district level are under the MOPH, providing secondary care. At sub-
district level, there are 9,976 health centres under the MOPH, mainly providing
primary care. There are a few hospitals under the Ministry of Education (mostly
medical schools), the Ministry of Defence and the Bangkok Metropolitan
Administration (BMA).
Table 1.2: Thai health care infrastructures in 2009: Pluralistic nature
Bangkok Provinces
( urban )
Districts
( rural )
Sub-district
( rural )
Villages
( rural )
N 1 75 796 7,255 74,435
Medical schools
Public 6 11 - - -
Private 1 - - - -
Specialized Hospitals 14 48 - - -
Regional Hospitals [37] - 25 - - -
General Hospitals
Public
– MOPH 4 69 - - -
– Other 22 62
Private 96 226 - - -
Community Hospitals [37] - - 734 - -
Private Clinics 3,878 13,793 - - -
Health Centres
MOPH - - - 9,768 -
Local government 76 - - 214 -
PHC Centres - - - - 66,223
Source: Thailand Health Profile 2008-2010
32
1.4.2 Private health facilities
Private hospitals play a key role in urban areas. They have been flourishing for the
past three decades. Private hospital capacity has grown rapidly from around 10% of
total hospital beds in 1985 to 20.6% in 2008 [17]. This was in response to rapid
double-digit economic growth, and the influx of low-interest foreign loans [39].
Although some of them were closed after the economic crisis in 1997, their numbers
have grown continuously since the economic recovery. Private health facilities in
Thailand range from drugstores, private clinics without in-patient beds, through to
private hospitals with in-patient beds. In 2009 there were 322 private hospitals in
Thailand, 30% of them located in Bangkok. The largest group of private hospitals
(approximately 32.3%) had between 51 and 100 beds, while those with over 200-
beds represented only 9.6% of the total (Figure 1.8). Over 200-bed private hospitals
are mostly located in Bangkok and other big cities, providing sophisticated tertiary
medical care.
Figure 1.8: Private hospitals by number of beds in 2009
Source: Thailand Health Profile 2008-2010
In 2011, there were 46 million patients using private hospitals. 44 million of these
visited out-patient clinics, while 2 million, approximately 5%, needed in-patient
treatment; this compares to an admission rate of 6% in public hospitals under the
MOPH and is thus a very different profile [30]. Private hospitals created gross
revenues of around 119 billion Thai Baht, approximately 3.9 billion USD, from
1‐10 beds, 8.1
11‐30 beds, 10.9
31‐50 beds, 17.7
51‐100 beds, 32.3
101‐200 beds, 21.4
> 200 beds, 9.6
33
hospital operations, and their net revenue was 47 billion Thai Baht, approximately
1.5 billion USD [30].
1.4.3 Human resources for health (HRH)
The health system is labour intensive [40]. The health workforce is central to every
health service system [41]. It is one of the most finite of resources, and health system
performance depends on the knowledge, skill and motivation of the people
responsible for the delivery of services.
Multiple cadres of HRH deliver health services in Thailand. As the country develops,
more professionals and fewer paramedics are being trained [42]. There are 18
medical schools (17 public and one private) and 10 dentistry institutes (nine public
and one private). Annual production capacity is approximately 2,500 new doctors
and 1,000 new dentists. Meanwhile, there are 74 nursing colleges and institutes (64
public and 10 private) with an annual production capacity of 7,000 new nurses.
However, there has been a continual shortage and inequitable distribution of HRH,
particularly geographically. Information from the National Statistics Office in 2000
shows that there is a gap in the distribution of the main professions between the
northeast region, considered the poorest area, and Bangkok. The imbalance is largest
in doctors, 9.46:1, and smallest in nurses, 1.97:1 (Table 3).
Table 1.3: Distribution of main cadres of HRH by region, 2000
Doctors Dentists Pharmacists Nurses
Number Pop. ratio Number Pop. ratio Number Pop. ratio Number Pop. ratio
Bangkok 9,504 668 2,720 2,336 2,764 2,299 17,389 365
Central 4,973 2,850 1,481 9,598 2,464 5,769 33,474 424
North 2,774 4,121 956 11,959 1,864 6,133 23,034 496
Northeast 3,294 6,322 1,136 18,332 1,916 10,869 28,887 720
South 1,890 4,279 673 12,017 1,346 6,008 16,867 479
Whole
country 22,435 2,758 6,966 8,882 10,354 5,976 119,651 517
Discrepancy ratio between Northeast : Bangkok
9.46 7.84 4.72 1.97
Source: The Population and Housing Census 2000, National Statistical Office
34
The distribution of doctors is influenced by multiple factors, including over-
specialization and lack of opportunities for further training [43]. However, also
significant has been the growth of private hospitals, resulting in an internal brain
drain of HRH, and especially the movement of specialists from public hospitals to
urban private hospitals. The percentage of doctors working in private hospitals has
doubled over the last twenty year, from 11.4% in 1987 to 20.9% in 2007 [17].
1.5 Conclusion
It is widely accepted that a substantial benefit of medical tourism comes in terms of
the economy, but this is not founded on firm empirical evidence of any extra revenue
resulting from medical tourism that would not otherwise (without medical care) have
accrued from ordinary tourism. Conversely, it has been argued that there is a
substantial cost to the domestic health systems of the service-delivering countries
from medical tourism, especially with respect to equity of access to healthcare by
domiciled patients [10,12,16,20]. These controversial aspects may result in policy
incoherence between trade and health [44]. However, current information concerning
these issues is relatively limited. Most of the literature is based on speculation rather
than empirical evidence [45].
There is still a lack of evidence on whether a country stands to gain or lose overall
from investment in medical tourism, and more specifically, who gains or loses with
respect to the domestic economy and the domestic health system. Hence, this study
seeks to establish empirically the impact of medical tourism on both the domestic
economy and domestic health system. Three objectives were established: to assess (i)
medical tourist characteristics; (ii) their expenditures; and (iii) their impact on the
domestic health system, specifically on private hospitals. Understanding the nature
and size of the industry, and its impact on the private sector, will also allow better
inference of the likely impacts, and the pathways for those impacts, on the public
sector; for instance, with respect to the likely crowding-out of local patients,
contribution to the ‘internal brain drain’, and the skewing of the forms of medical
care receiving investment. Furthermore, there is also a need to provide some
35
indications of whether medical tourism can provide a “net” benefit, and identify
significant factors which may shift this balance to ensure that a country can move
closer to the “net” benefit by maximizing the opportunities and minimizing the risks.
1.6 Thesis outline
This thesis focuses on the implications of medical tourism on the domestic economy
and the health system of Thailand. While the focus is primarily on the private sector,
conclusions on ‘spill-over effects’ for the public sector are included. The thesis
provides a survey of their characteristics, a demonstration of their contribution to the
Thai economy and an investigation of their possible implications on the domestic
health system. Seven chapters follow this introductory chapter.
Chapter Two presents a literature review of the tourism and medical tourism
industries, and the interrelationship between these two arenas. The gaps in the
literature are outlined.
Chapter Three presents the conceptual framework of this study. Research
methodologies are described to demonstrate how to answer the key and specific
research questions in each sub-study contained in the thesis.
Chapter Four explores the characteristics of medical tourists from various aspects,
including their demographic and service profiles. Comparisons of the characteristics
of medical tourists and non-medical tourists, and medical tourists and Thai private
patients are presented.
Chapter Five analyses the economic impact of medical tourists on medical and
tourism elements. A comparison of the expenditures of non-medical tourists and Thai
private patients is also provided. Moreover, the expenditure of their companions is
investigated as well.
Chapter Six analyses the implications of medical tourism on the Thai health system.
Various key informants in private hospitals are interviewed to demonstrate whether
36
medical tourists displace domestic patients. Issues concerning whether there is any
discrimination between medical tourists and Thai private patients, and how hospitals
obtained additional resources to cater for foreign demand for health services, are also
investigated.
Chapter Seven synthesizes the findings of the study and presents a discussion of the
issues involved in establishing whether a country gains or loses from serving medical
tourists. Policy recommendations are also provided to guide policy makers to
generate effective policies.
37
Chapter Two
Literature review
38
Chapter 2 Literature review
2.1 Search methodology
In order to establish a better understanding of the implications of medical tourism for
the domestic economy and health system, a review of the literature related to these
issues was conducted. The search methodology comprised two components; a
primary literature search of electronic bibliographic databases, and a secondary
literature search for statistical data and policy documents relating specifically to
Thailand, which were unlikely to be found in the primary search.
The primary literature search was carried out in various electronic databases
including Global Health, MEDLINE, Web of Science, Social Policy and Practice,
Health Management Information and EMBASE. Search terms used were “Medical
tourist”, “Medical tourism”, “Health tourism”, “Trade in Health Service” and “Cross
border patient”. These search terms were adopted for each database and used across
fields such as title, abstract, key word and subject heading, from the earliest date
available until 31 October 2013. Papers not related to medical tourism, and/or which
were in languages other than English or Thai were excluded from the review. From
this preliminary search, approximately 342 papers were initially identified. These
were thoroughly reviewed and 129 were judged to be relevant to the thesis
objectives.
The secondary literature search was for specific statistical information and policy
documents relating to Thailand, which were unlikely to be included in the
bibliographic databases above. For this literature and data, domestic websites related
to the thesis objectives were identified, as follows:
Ministry of Public Health - http://www.moph.go.th/
Ministry of Commerce - http://www2.moc.go.th/
Ministry of Tourism and Sports - http://www.mots.go.th/
39
The Tourism Authority of Thailand – www.tat.or.th
National Statistical Office – www.nso.go.th
Office of the National Economic and Social Development Board – www.nesdb.go.th
National Health Commission Office – www.nationalhealth.or.th
In addition, the websites of many private hospitals were also searched.
It was found that most literature on medical tourism contained very limited
information and sparse and out-of-date data [46]. Moreover, most were based on
speculation rather than empirical evidence [45]. Smith (2011)[47] reviewed 63
papers related to medical tourism and the role of bi-lateral trade, and found that very
few papers provided empirical data while others mentioned statistical information
without being a primary study themselves. The most popular source of statistical
information in the medical tourism literature was from newspapers and brokerage
claims [45, 46].
2.2 What is medical tourism?
The term “medical tourist” is still inconclusively defined [5]. The Medical Tourism
Association defines “medical tourism” as a situation in which people living in one
country travel to another country to receive medical care, receiving care equal to or
better than that which they would receive in their own country. Medical tourists were
defined as people who travelled in order to receive medical care because of easier
affordability, better access to care or a higher standard of quality of care. This new
and distinct niche market targets medical need in developed countries [48, 49]. In
essence, medical tourism is an act by patients who travel abroad to seek medical care
[50, 51]. Most definitions focus on medical services ranging from simple health
check-ups; non-invasive treatments not involving hospitalization, such as dental care;
and some cosmetic procedures, to more invasive and complicated treatments such as
heart operations and major orthopaedic operations. In some countries, it includes
controversial procedures such as reproductive procedures and organ transplants,
which raise concerns about patient safety and ethical considerations [47, 52-58].
Alternative treatments may also be provided, for example Ayurvedic medicine in
India. Even though a successful outcome from a specific medical procedure is
40
considered the main purpose of travel, medical travellers also experience other
aspects of tourism, sampling a different culture, and enjoying leisure and shopping
activities [59]. Some literature expands the definition of these patients into other
arenas as well as health; direct and indirect engagement in tourism and other
activities is included in the definition of a medical tourist [46], but passive health
activities, such as spa and wellness centres, are conclusively excluded from the
medical tourism arena. These kind of non-invasive and health-promotion activities
are termed “Health tourism” or “Wellness tourism” [45].
The term “Health tourism” covers all forms of health-related tourism which doesn’t
involve actual medical treatment, but assumes incidental benefits in an amenable,
relaxing context. A ‘spa’ is typical of the sort of service usually mentioned in respect
of health tourism. The European Union's High Level Group on Tourism and
Employment reported in 1998 that “Spa, health and fitness facilities” would be one
of the fastest growing segments in tourism [60]. The term “Wellness tourism” is
widely used in European countries. The quality of services is a significant
competitive factor between countries [61].
2.3 Globalization of medical tourism
Globalization currently challenges most policy makers and public health practitioners
[62, 63]. In the past, globalization was often been seen as being a purely economic
process associated with greater ‘liberalization’ of trade. Currently, it is considered to
be a more comprehensive phenomenon causing considerable changes in culture,
politics and other aspects of society [64]. It has a positive impact on health by
increasing a country’s economic growth and the availability of goods, and
introducing difference concepts of well-being. However, it also has a negative
impact due to the market penetration of “bads” such as tobacco and alcohol [65].
The globalization of health services is illustrated by increasing cross-border
movement of patients and health professionals and also by international investment
in health services and e-health [66].
41
“Medical tourism” is an explicit manifestation of globalization which has emerged
in the 21st century, but actually has a long history, especially emerging in the 18th
century when travelling was closely linked to an increase in well-being and
recreation. “Taking the waters” in spas in many parts of Europe was an early
example of well-being tourism [49]. More recently, many tourists travel for
alternative care, such as Ayurvedic medicine, yoga and meditation; this is considered
another form of “Health tourism”, specifically for recreation and an increase in well-
being. For many year, medical care in developed countries, such as the US, attracted
wealthy patients from developing and less developed countries who went in order to
receive technologically advanced healthcare services not available in their home
countries [29]. Currently, a reverse phenomenon exists, where patients from
developed countries travel to less developed countries to seek economical and
prompt medical services.
It is difficult to determine the precise scale of this industry, as various definitions of
medical tourism exist [5, 67]. Official data concerning medical tourism at national
level is limited, as there is no means to access it and no independent body to verify it
[5]. Routine data is ineffectively collected, and is mostly from the private sector [45].
Most of the available national data is based on estimation, substantially overstated
[5]. McKinsey & Company estimated that the medical tourism industry worldwide
generated approximately 60 billion USD in 2006 and reached 100 billion USD in
2012[68].
2.3.1 Source and destination countries
The main source countries are North America, Western Europe and the Middle East
where patients have high purchasing power [49]. In 2010, an estimated 63,000 UK
patients travelled abroad for medical care mainly for fertility, cosmetic and bariatric
treatments [69]. Approximately 50,000-120,000 US residents travelled abroad to
obtain medical services in 2007 [70]. However, the USA and the UK import and
export health services. Many international patients come to USA and UK for medical
care as well [69, 70].
42
Medical tourism companies, called “Brokers”or “Medical tourism facilitators”,
stimulate the growth of this industry by linking patients and destination services [54,
71]. They act as a ‘one-stop’ service offering information and a variety of services to
meet patient needs [72]. These agencies provide a list of hospitals and doctors for
selection, and arrange hospital appointments, transportation and accommodation
[67]. They sometimes provide follow-up services with doctors in the patient’s own
country. Information concerning medical services is also presented on websites
which helps in matching patients with a destination country. Information on these
websites varies from the general for example concerning travel and accessing
services abroad, to the more specific, such as details of the services available.
The main destination countries include several in Eastern Europe, Latin America,
Asia and to a lesser degree Africa. Medical tourism has been a significant growth
industry in many regions. In 2007, Thailand received 1.5 million medical tourists,
and was the largest provider of these services. India, Singapore and Malaysia
received 450,000, 410,000 and 300,000 incoming patients respectively. The
Philippines, Korea and Taiwan are new players in this market [4]. Other regions,
such as Jordan, Hungary and Mexico, have served patients from neighbouring
countries. Costa Rica, Brazil and South Africa are also well-known for providing
cosmetic surgery for overseas patients [4].
Most exporting service countries have to differentiate themselves by promoting their
attractiveness in terms of the quality of services, competitive prices and their
specialized services. Cuba has developed a specialization in plastic surgery and
dental care [49]; the Caribbean Islands developed a medical tourism industry from
their existing tourism-oriented economy [73]; Eastern European countries have a
reputation for cosmetic and dental care; “Surgeon and Safari”, which explicitly links
medical care with tourism, is used as an advertising slogan to attract patients to South
Africa; and Israel specializes in female infertility and in-vitro fertilization [49]. In the
1970’s, Thailand was initially famous for gender reassignment and then changed to
providing cosmetic surgery. India promoted themselves as providers of Ayurvedic
therapy, and coronary bypass and cosmetic surgery.
43
Many countries have introduced strategies to encourage medical tourism, such as tax
exemptions for foreign investment in health facilities, or tax reductions for importing
advanced sophisticated medical equipment. To facilitate overseas patients obtaining
services, the Indian government introduced a special visa, called an “M” visa, for
these patients [15].
2.3.2 Regional effects of movement
Current information suggests that the majority of international patients travel within
their regions. Social, cultural and linguistic factors are the main reasons cited [74]. A
growth in the numbers of the wealthy middle classes has contributed to increased
travel for services unavailable in their various home countries [75]. For instance,
around 70% of medical tourists in Singapore are from the Association of Southeast
Asian Nations (ASEAN). The majority of medical tourists in Malaysia,
approximately 72%, are from Indonesia, followed by patients from Singapore,
approximately 23% [76]. Cuba is a very popular destination for visitors from the
Caribbean and Central America. Tunisia serves customers from neighbouring Libya
[77]. Yemeni patients travel to India and Jordan for services [78]. Jordan also caters
mainly for patients from the Middle East. Some pregnant women in China come to
Hong Kong to give birth [79].
Similarities of culture and religion are contributing factors for regional movement.
Musa et al (2012) reported that apart from price and quality of services, cultural and
religious similarities constituted the third most important reason for medical tourists
visiting Kuala Lumpur [80]. However, multiple factors affect patient choice,
including shorter distances to providing hospitals, language similarities, differences
in cost and length of waiting lists for example are reasons for the cross-border
movement of patients in the Euro region Meuse-Rhine, covering provinces in
Germany, Belgium and the Netherlands [81].
44
2.4 Why do they travel?
A more recent trend is patients travelling from developed countries to less developed
countries to obtain medical care [49]. Key ‘push’ factors are high healthcare costs
and long waiting lists for particular procedures in developed countries such as the
US, the UK, and Canada [27, 82]. Meanwhile, there is an increase in well-trained
medical staff and high quality services in destination countries.
2.4.1 Push factors in source countries
The main contributing factors pushing patients from developed countries are high
healthcare costs, long waiting times for medical care and lack of particular services
[8, 46]. Americans form the largest group of medical tourists. Cost is a particular
factor for US citizens given the prohibitive cost of healthcare there [26, 83, 84]. This
continues to fuel growth in the medical tourism industry [28, 85]. In Canada, the UK
and some other countries in Europe, some non-emergency operations have waiting
times of more than six months. Some reports have suggested that in 2005, 50,000 UK
patients went to Thailand alone [86]. In Australia, around 7-8% of travel insurance
claims are for dental care abroad [87]. Patients in many European countries travel to
Italy and to several countries in Eastern Europe for reproductive services unavailable
in their home country. Cultural familiarity is one contributing factor for patient
mobility [88]. Mexicans dwelling in the USA tend to return home to obtain familiar
medical services [89]. People of the Indian diaspora in the UK often return to India
for medical care [90]. Acquaintance with a healthcare system, trust in the service
providers and communication through the same language is important [91].
2.4.2 Pull factors in destination countries
o Competitive price
Cost saving is considered the most significant benefit for overseas patients [67].
Lower labour costs, inexpensive drugs and lack of malpractice insurance, are major
determinants for countries exporting services in making their price competitive [92].
45
Total health service expenses, including travelling and accommodation costs, are still
cheaper when compared with the same treatment in the US or the UK [28, 93].
Currently, reimbursement for treatment carried out abroad is allowed by many
insurance companies [9].
However, there is also price competitiveness among destination countries. Thailand
and Malaysia offer a competitive price compared with Singapore for example [25],
and India also charges attractively lower prices than many of its competitors (Table
2.1) [67].
Table 2.1: Comparative cost of medical procedure by country
Procedure US. India Thailand Singapore
Heart bypass 130,000 10,000 11,000 18,500
Heart valve replacement 160,000 9,000 10,000 12,500
Angioplasty 57,000 11,000 13,000 13,000
Hip replacement 43,000 9,000 12,000 12,000
Hysterectomy 20,000 3,000 4,500 6,000
Knee replacement 40,000 8,500 10,000 13,000
Spinal fusion 62,000 5,500 7,000 9,000
Source: AMA-OMSS Governing Council Report B June 2007-Appendix A
o High quality medical service
Apart from economics, quality of care is considered an important issue for
international customers [94]; “First world health care at a third world price” slogan is
commonly used. International accreditation by the Joint Commission International
(JCI), the global brand of hospital accreditation organizations, and highly proficient
medical staff trained in the US and UK, are often cited by suppliers as a guarantee of
quality. A “Brand” corporation with state-of-the-art medical institutes in the US and
UK is also widely used in marketing and advertising [78]. Many hospitals deliver a
high level of customer services which is blurring the lines between hospital and
hotel. Attentive private care, luxurious rooms, outdoor pools, room service and a
private limousine service are advertised in order to attract customers [78].
46
A combination of various factors including cost, hospital accreditation,
infrastructure, quality of care and physician training contribute to the decision by a
patient to travel in order to receive healthcare [95]. Information about medical
treatment is also extremely important: for example, Canadian patients have indicated
that information, especially by word-of-mouth, lies behind the decision-making
process used when thinking about travelling abroad [96], and rapid technological
developments make it far easier to access healthcare information [97].
2.4.3 Who pays for services abroad?
When people wish to travel abroad for healthcare, public health insurance schemes
are comparatively restrictive, while private health insurance is more flexible. If
patients have no third party covering their medical expenses abroad, they have to be
responsible for funding themselves. However, there are a variety of funding
mechanisms available to help pay for these services, offering partial or complete
subsidy [91]: private health insurance, which covers certain types of patients and
services; national social protection legislation, which may allow patients to receive
treatment abroad: for example, Canadian patients can travel abroad for some
operations, subsidized by a publicly financed scheme [96]; purchasing agencies,
which may have contracts with foreign health providers; and the government, who
may also have contracts with foreign health providers, and may subsidize expenses
arising from medical care from public funds [91].
2.5 Implications of medical tourism
2.5.1 Economic implications
Medical tourism contributes economic benefit to source countries. In the US, as
health care costs have increased and quality of service declined, many businesses
have tried to find more options to control costs [98]. Some US states have introduced
bills which allow employees to go overseas for medical treatment. In addition, some
health insurance companies provide options for overseas treatment for their clients
[6, 67, 85]. Source countries will benefit from the economic effect of medical
47
tourism. Mattoo and Rathindran (2006) estimated that if a percentage of US patients
needing low-risk surgical procedures go abroad, the annual saving could reach US$
1.4 billion [99]. Kumar et al (2011) estimated that in 2011 the US healthcare industry
would lose USD 20-30 billion by patients travelling to India and Thailand for three
major operations: knee replacements, hip replacements and heart bypasses [100].
Outsourcing medical services is considered to be a safety net for uninsured and
under-insured Americans who cannot afford high-cost US healthcare [71].
For destination countries, medical tourism generates foreign exchange earnings,
strengthening their economy [101]. Overseas patients are likely to be more lucrative
customers; a study in the UK conducted by Hanefeld et al demonstrated that 7% of
overseas patients in the UK generate approximately 25% of private healthcare
revenues [69]. Governments in countries such as Thailand, Singapore, Malaysia and
Hong Kong have employed many strategies to encourage private sector involvement
in this global market [25, 102]. Well-coordinated government programs and public-
private initiatives to increase the market share of the industry have been established.
Advertisement by international road shows and promotion via the internet aims to
demonstrate competitiveness in price and quality. India has a special medical visa
which extends entry validity to one year for medical tourists [26].
It is estimated that, worldwide, there are around 4 million international patients every
year [74]. The revenue generated by these medical tourists is very attractive,
estimated at around US$ 20-40 billion annually. The Asia Medical Tourism Analysis
report (2008-2012) states that, in 2007, total medical tourism revenue in Asia was
around US$ 33.4 billion, or around 13% of the global medical tourism market [82].
Chew Ging Lee (2009) reported that the development of health systems has a
positive effect on international tourism in the long term [103]. However, no cost-
benefit analysis of these policies has been undertaken to date.
“Trickle-down” economics is expected to provide another benefit from medical
tourism throughout many areas in destination countries [46]. However, in some
countries, India being one example, there is still a lack of enforcement of regulations
to ensure that revenues from medical tourism are allocated back into public health
48
care [104]; policies are needed in each country to ensure that income from medical
tourism is reinvested for the public benefit.
A significant increase in medical tourism is closely linked to direct medical
intervention, particularly in developing countries. However, most literature does not
describe the “tourism element” separately from the “medical element”, particularly
the ways in which medical tourism contributes to the tourism industry. Information
about the revenue from medical tourists quoted in literature about tourism is
ambiguous; it is unclear whether the figures represent medical expenditure alone, or
whether they include other tourism expenditures.
2.5.2 Health system implications
The risks presented by the medical tourism industry relate to equity and access to
healthcare by domestic patients [101, 105]. It has been claimed that an increase of
investment in private hospitals catering to international patients would widen
existing inequities in society. In many countries, these investments need long term
government subsidy. National resources may shift from local patients in the public
sector to well-off locals and overseas patients in the private sector. This diversion of
resources may exacerbate disparities in the health system [106]. However, there is a
counter-claim that more investment in the private sector for overseas customers
would increase the chance for locals to access sophisticated medical equipment and
high-quality services. In the case of India, there is no evidence to support this
assertion [107].
It is also a concern that an increasing number of overseas patients may increase an
internal “brain drain” of highly skilled health professionals from the public to the
private sector [15, 16, 46]. On the other hand, it is sometimes argued that private
hospitals can attract doctors based abroad back home to practise in their own country
again. [108]. Some countries, such as Barbados, have introduced medical tourism
into their health system in order to retain skilled health professionals: hospitals
targeted for serving foreigners are mostly funded by foreign investors, and the
49
employment of local nurses, technicians and other hospital staff can help to reduce
emigration [76].
Flourishing medical tourism requires an investment in infrastructure and consumes
more resources in terms of investigations and manpower, which could affect the
overall health care cost of a country in the long term. Domestic demand on the
private sector is directly affected by medical tourism and it is possible that healthcare
cost will become unaffordable for domestic patients [76, 109].
2.5.3 Patient implications
The key concern of patients travelling abroad for healthcare is the quality of that care
[110]: that it will be of a lower quality compared to that available in the home
country is the main concern. Thus, guarantees of quality of care have become
extremely important for hospitals in destination countries. Certification by
international quality assurance agencies, such as Joint Commission International
(JCI), the Australian Council for Healthcare Standards and the Canadian Council on
Health Services, is employed to reassure customers that an international standard of
care will be provided.
Meanwhile, a rapid growth of medical tourism challenges source countries to justify
their prices, service quality and personalized care [71, 111]. The American Medical
Association (AMA) has launched guidelines on medical tourism for patients,
employers, insurers and medical tourism companies so that that they have a better
awareness of coordinating care before and after operations [112]. Meanwhile, some
studies have reported that morbidity and mortality following organ transplants
undertaken abroad have considerably increased [113]. In 2007, a survey from the
British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS)
expressed concerns about UK patients presenting with complications following
cosmetic procedures undertaken abroad [114].
Legal issues concerning professional malpractice is another concern [115-118]. Some
patients overestimate the benefits and underestimate the risks in destination countries
50
less concerned with medical legislation and professional codes of conduct [71].
Patients harmed by medical malpractice may not claim for legal redress in the
country which provided the services [71]. There will be legal challenges for medical
travellers who try to claim compensation as a result of overseas services [117, 118].
Continuity of care after returning to the home country is another concern [93, 119].
Patients undergoing procedures abroad may have post-operative complications which
manifest when they return home. Disruption of treatment and inadequate information
about care received outside the country presents domestic physicians with difficulties
in monitoring and following up with their patients [71, 120].
Medical tourism has the potential to create both positive and negative implications
for both source and destination countries. Although it may make a positive
contribution to a country’s economy, the government of that country must be aware
of any possible negative impact. Governance, service delivery, financing, human
resource management and regulation are key concerns [121]. Proper management
and regulation could mitigate these negative effects and protect access to care for
local patients.
2.6 Conclusion
There is very little empirical evidence in the area of medical tourism and there is a
clear need for more research to generate greater understanding of this issue [45, 46,
122]. With regard to medical tourists, most literature discusses their numbers at a
global level, while some tries to provide data at national level, using existing
secondary data which is both patchy and outdated. Moreover, the total number of
medical tourists presented is not broken down into tourists who travelled with the
intent to seek medical services and other groups such as expatriates and ordinary
tourists who fell ill by chance. There is no clear picture of the specific characteristics
and behaviours of medical tourists as distinct from other tourists.
With regard to the impact of medical tourism, most literature describes the effect on a
country’s economy as positive in terms of increasing revenue. However, there is no
51
reliable evidence on how much revenue medical tourism adds to revenue brought in
by tourism in general; its particular contribution might be marginal. Furthermore,
there is no evidence of the impact of medical tourists on private and/or domestic
patients in terms of resource allocation; whether it increases inaccessibility and a
two-tier system; these patients might be a small addition to the current level of
private patients within a system and have little or no effect. Currently, there are no
empirical studies assessing both the economic and health system implications
simultaneously, in order to try and generate a more holistic assessment of any
additional value the medical tourist has on tourism. This study tries to fill that gap,
by investigating critical data from the private sector.
52
Chapter Three
Aim, objectives and research methodology
53
Chapter 3 Aim, objectives and research methodology
From the previous chapter, it is clear that there is a lack of explicit understanding of
who medical tourists actually are and how much they differ from local patients in
terms of demography and services used. Moreover, there is also very little empirical
evidence on how much they affect a destination country in terms of the domestic
economy and the domestic health system [75, 123].
This study aims to contribute to this gap in the literature through assessing the impact
of medical tourism on the Thai economy and private health system. It then explores
the potential effect on the public health system, following pathways such as those
outlined in Section 3.1. Thailand was chosen as a suitable country for this case study
due to its significant medical tourism sector, large number of ordinary tourists, and
because the government has a policy of increasing the level of medical tourism. This
chapter outlines the study framework and approach used to investigate and evaluate
the possible impact of medical tourists on the national economy and domestic health
system. The first section presents the conceptual framework and the objectives of
the study. The second section describes the research methodology used for data
collection and analysis. The last section addresses the ethical considerations of the
study.
3.1 Conceptual framework
To describe the main implications of medical tourism, a conceptual model of the
study is presented in figure 3.1. This conceptual framework focuses on ways in
which the presence of medical tourists could affect the income and expenditure of the
domestic economic and health systems.
Medical tourists contribute revenue to the domestic economy in two ways. First, that
directly related to the main purpose of this travel sector: “medical care”. This
54
includes the cost of physicians, other health staff, hospitals, medications and medical
devices.
The second is the “non-medical expense” which pertains to expenses related to the
role of ‘tourist’. In this study we will use the term “tourist expense” when referring
to “non-medical expense”. The tourist expense includes collateral goods and services
such as airfares, local transportation, food, entertainment and souvenirs. During each
visit, the medical tourist, as well as any companions and relatives, will generate
revenue in both components for the destination economy. The tourism expense will
be an add-on to the value of medical care services and, at the same time, the medical
expense will enhance the value of the tourism industry.
According to the conceptual framework, the revenue from medical tourists is a part
of overall private hospital income, derived from many areas including operating
costs, administrative costs, corporate tax for government income and income for
shareholders. The concerns identified over any undesirable impact of medical
tourism are in respect of equity and access to health care. The growth of this market
may result in the creation of a dual market structure in the destination health system
[77]. Domestic resources may shift from the public sector, or even within the private
sector, to serve foreigners rather than nationals. Health personnel may tend to move
from public facilities which pay less and have a substantial workload, to private ones,
particularly those serving overseas patients, which pay more for less work. Increased
shortages in public resources would be likely to induce educational institutes to
increase their production and even shift training towards international customer
services.
The main concern relating to the effect of medical tourism on local health care
systems in destination countries is whether the inflow of foreign demand could push
out local patients. As many developing countries already have a two-tier health care
system, an increase in foreign patients might accentuate this inequality.
However, the extent of such undesirable impacts depends on any existing spare
capacity among private providers and on how hospitals manage and allocate their
55
resources between medical tourists and local patients. For instance, profits from
medical tourism could be used to invest in facilities for domestic patients, and spare
capacity in new technology could also be made available to local patients.
56
Figure 3.1: Conceptual model on impact of international patients
Private Hospitals for medical services
Medical tourists1.5 millionvisits/yesr
Domestic private patients43 million visits/year
Public hospitals
Tourism-related services(Food&restaurants, transportations,accommodations, entertainments and
retail shops)
Non-medical tourists14 million visits/year
Tourism revenue frommedical tourists
Tourism revenuefrom non-medical
tourists
Medical revenue frommedical tourists
Medical revenuefrom domestic
patients
Medicalexpenditure
Tourismexpenditure
Additional health resourcesfor medical tourists
Domesticsource
Internationalsource
Healthcareworkers
Otherresources
Domestichealthcareworkers
Other domesticresources
Other privatehospitals
Educationalinstitutes
Increase production
Shift in training
Operating cost
Administrative cost
Investment
Corporate tax
Shareholders
Thais
Foreigners
57
3.2 Aim and objectives
The overall aim of this study is to assess the impact of medical tourists on the Thai
economy and domestic private health system. The first main research question asks
whether medical tourists add to the economy of the destination countries, in terms of
medical and tourism elements, and whether they differ from non-medical tourists. As
the majority (99%) are treated in private hospitals, the second main research question
is what impact medical tourists accessing care in private hospitals in Thailand have
on the provision of healthcare in these hospitals, and to what extent the presence of
these patients affects domestic private patients. The study has three objectives, as
follows:
Objectives:
1. To assess the characteristics of medical tourists compared with those of non-
medical tourists and domestic private patients
2. To assess the expenditure of medical tourists on medical care and tourism versus
that of non-medical tourists
3. To assess the impact of medical tourists on private hospitals versus the impact of
domestic private patients.
3.3 Study design and research methodology
This study focuses on an exploration of the impact of medical tourists by using
Thailand as a case study. It aims to assess the impacts of medical tourists on the
domestic Thai economy and private health system by comparing the characteristics
of these medical tourists to non-medical tourists and domestic private patients. Five
leading private hospitals serving international patients in Thailand were purposely
selected as study areas. Multiple approaches, quantitative and qualitative, were
applied to ensure that the evidence obtained enabled the key research questions to be
answered. The overall framework of this study is demonstrated in figure 3.2.
58
In order to achieve the three objectives mentioned above, this study is separated into
three sub-studies. Sub-study 1 seeks to analyse whether and how medical tourists
differ from non-medical tourists and domestic private patients by comparing them
from various aspects, such as their demographic profiles, treatment received and
length of stay in Thailand. Comparing country of origin of medical tourists and non-
medical tourists allows an assessment of whether the national strategy of promoting
international patients could open new markets for tourism that Thailand is not
currently benefitting from. Comparing service profiles between medical tourists and
domestic private patients will allow an analysis of the differences between them and
assist in forecasting the service demand of foreigners in the future, which might
affect the domestic resource pool.
Sub-study 2 focuses on the impact of medical tourists on the domestic economy. It
seeks to analyse how much medical tourists spend on the medical and tourism
elements of their visit. A comparison with non-medical tourists and domestic private
patients will demonstrate how much they differ from each other and whether
expenditure from medical tourists is a marginal gain; in other words, are they more
profitable than non-medical tourists? An understanding of how much medical tourists
and their companions add to tourism revenue in general is very important for
estimating their actual additional economic impact. Moreover, this section also tries
to demonstrate whether spending differs from region to region: for example, patients
from long-haul and nearby regions. It also identifies key factors influencing
spending. These findings will help policy makers in identifying which groups of
medical tourists are potentially the most profitable to the country, and in establishing
strategies for enhancing tourist spending to achieve the maximum benefit.
Sub-study 3 focuses on the impact of medical tourists on health care provision in
private hospitals. This section will demonstrate whether medical tourists displace
domestic private patients, by analysing the differences in the medical care they
receive. If they are treated differently, there is a need to establish why and how
hospitals justify priorities in resource allocation between international patients and
Thai nationals. The pattern of service profiles in sub-study 1 will be elaborated in
this part, to explore how hospitals provide resources to cater for international
59
customers; for example from their spare capacity, importation or domestic
recruitment. The approach for extra resources gained would guide policies on
increasing health personnel, shifting the balance of training programmes to produce
the required personnel or strengthening mutually-utilized resources between public
and private sectors, in order to mitigate any negative impacts on the domestic health
system. A qualitative approach is employed in this sub-study to elaborate the
quantitative findings in Sub-studies one and two.
3.3.1 Specific research questions:
Specific questions have been developed based on the study aims and research
questions and have guided the data collection process.
Sub-study 1: Assessing characteristics of medical tourists VS non-medical tourists
and domestic patients
1.1 How do medical tourists differ from non-medical tourists? In terms of:
1.1.1 Region of origin
1.1.2 Gender
1.1.3 Age
1.2 How do medical tourists differ from domestic patients? In terms of:
1.2.1 Gender
1.2.2. Age
1.2.3 Type of disease
1.2.4 Types of procedures
1.2.5 Length of stay
1.2.6 Payment methods
1.3 How do medical tourists differ among regions? In terms of:
1.3.1 Gender
1.3.2 Age
1.3.3 Type of disease
1.3.4 Types of procedures
1.3.5 Length of stay
1.3.6 Payment methods
60
Sub-study 2: Assessing the expenditure of medical tourists on medical care and
tourism
2.1 Does the tourism spending profile of the medical tourist differ from that of
non-medical tourists?
2.2 Does the tourism spending profile of the medical tourist’s companions differ
from that of the companions of non-medical tourists?
2.3 What are the factors influencing tourism expenditure for medical tourists
and non-medical tourists?
2.4 Does the medical spending of medical tourists differ from domestic Thai
patients?
2.5 Does the medical spending of medical tourists differ by region?
Sub-study 3: Assessing the impact of medical tourists on domestic private hospitals
3.1 Are medical tourists treated differently from domestic patients (i.e. are they
more costly to treat) – and if so, why?
3.2 How are resources required for medical tourists obtained? And on what
basis?
3.3 How are revenues from medical tourists allocated?
All information obtained from the three sub-studies was analyzed to identify whether
Thailand will gain or lose overall from the presence of medical tourists, through an
assessment of the “net” benefit, presented through the combination of effects on the
domestic economy and health system. Information will also be used to identify
factors used to balance these implications, by maximizing the opportunities and
minimizing the risks.
3.3.2 Study areas
Thailand was selected as the country for this case study as it has a leading medical
tourism industry and is a well-known tourist destination. Five private hospitals were
selected for this study. These were:
61
1. Bumrungrad International Hospital
2. Samitivej Hospital
3. Bangkok Hospital
4. Bangkok Pattaya Hospital
5. Bangkok Phuket Hospital.
The international patient survey of DEP in 2007 indicates that there were
approximately 55 hospitals, both public and private, servicing international patients.
The vast majority of international patients were in private hospitals; only 0.9% used
public hospitals. The five hospitals listed above had a majority market share of
around 63% (Table 3.1). The rest of the hospitals typically had less than 1% of the
market share, and were located in large provinces and principal tourist areas. This
study assumes that the majority of international patients in these hospitals were
ordinary tourists who found themselves unexpectedly in need of medical care.
Table 3.1: Hospital ranking by international patient services in 2007
Ranking Hospital Beds International
patients in
2007
% Market share for
international patients in
2007
1 Bumrungrad International Hospital 554 426,398 31.04
2 Samitivej Hospital 296 182,807 13.31
3 Bangkok Hospital 550 131,120 9.54
4 Bangkok Pattaya Hospital 364 63,586 4.65
5 Bangkok Phuket Hospital 317 58,941 4.29
Total 2,081 862,852 62.83
Source: Department of Export Promotion, Ministry of Commerce
Bumrungrad International Hospital, Samitivej Hospital and Bangkok Hospital are
located in Bangkok, capital city of Thailand (Figure 3.2). Bangkok Pattaya Hospital
and Bangkok Phuket Hospital are located outside Bangkok (Figure 3.2). Bangkok
Pattaya Hospital is in Chonburi province in the eastern part of Thailand and Bangkok
Phuket Hospital is in Phuket province in the southern part of Thailand. Both
hospitals are located in high-density tourist destination provinces.
62
Figure 3.2: Location of the five targeted private hospitals in the study
All hospitals in this study are well known as leading private hospitals in terms of
serving international patients in Thailand. They are marketed to international patients
as providing highly-specialized tertiary care and different service packages. They
also provide specialized services for foreigners, such as translators and special areas
for overseas groups.
63
3.3.3 Terms and definitions
1. International patients
The term “international patient” when used in this study means non-Thai patients
visiting hospitals in both out-patient and in-patient departments. This term includes
medical tourists, expatriates and international tourists who fall ill while travelling in
Thailand.
2. Medical tourists
The study uses the term “medical tourists” as the target population. The term refers
to international patients from developed and developing countries who travel to
Thailand for the primary reason of obtaining medical services. Expatriates and
ordinary tourists who became ill while travelling are excluded from the study, as are
other forms of treatment related to “health and wellness tourism”, such as spas and
massages.
The key specifications for medical tourist in this study include:
Foreign patients from developed and developing countries who travel to Thailand for
the primary reason of obtaining medical services, and who are not employers or
employees of public/private or domestic/international organizations in Thailand.
3. Non-medical tourists
The term “Non-medical tourists” in this study means ordinary international tourists
or other tourists who come to Thailand for purposes other than to receive medical
services.
64
4. Being-ill tourists
The term “Being-ill tourists” in this study means general international tourists who
are unintentionally ill while travelling in Thailand.
5. Domestic private patients
The term “Domestic private patients” in this study means Thai patients who obtain
medical care as out-patients or in-patients in the five targeted hospitals.
6. Within-region
The term “Within-region” in this study refers to people who come from the Asian
mainland. This included Southeast Asia, East Asia, South Asia, Central Asia and the
Middle East
7. Long-haul regions
The term “Long-haul regions” in this study refers to people who came from other
continents apart from the Asian mainland. This includes North America, Central
America, Latin America, Europe, Africa and, Australia and Oceania.
65
Figure 3.3: Overall framework of the research design
Data collection 1. Medical records of medical tourists in 2010 2. Medical records of domestic patients in 2010-10 3. Tourism database from international tourist survey of MOTS in
2010
Data collection 1. Medical records of medical tourists in 2010 for medical
expenditures (use data in part 1) 2. Medical records of domestic patients in 2010 for medical
expenditures (use data in part 1) 3. SAQ survey for tourism expenditures of medical tourists in 2012 4. Secondary data from international tourists survey by TAT in 2010
Data collection Interview
Data analysis 1. Independent t-Test for continuous variables 2. Chi-square for categorical variables 3. ANOVA
Data analysis 1. Independent t-Test for continuous variables 2. Multiple regression analysis
Data analysis Applied framework analysis for qualitative data
Specific questions 1.1 How do medical tourists differ from non-medical tourists? 1.2 How do medical tourists differ from domestic patients? 1.3 How do medical tourists differ between regions?
Specific questions2.1 Does the tourism spending profile of medical tourists differ from
non-medical tourists? 2.2 Does the tourism spending profile of medical tourists’
companions differ from non-medical tourists? 2.3 What are the factors influencing tourism expenditure for medical
tourists and non-medical tourists? 2.4 Does the medical spending of medical tourists differ from
domestic Thai patients? 2.5 Does the medical spending of medical tourists differ by region?
Specific questions 3.1 Are medical tourists treated differently from domestic patients
(i.e. more costly to treat) – And if so why? 3.2 How are resources required for medical tourists obtained? And
on what basis? 3.3 How are revenues from medical tourists allocated?
The impact of medical tourism on the domestic economy and health system: A case study of Thailand
Sub-study 1: Assess characteristics of medical tourists VS non-medical tourists and domestic patients
Sub-study 2: Assess the expenditures of medical tourists on medical care and tourism expenses
Sub-study 3: Assess impact of medical tourists on private hospitals
Key research questions 1. What do medical tourists add to the economy, in terms of medical and tourism elements, compared with non-medical tourists? 2. What impact do medical tourists have on healthcare provision in private hospitals compared to domestic private patients?
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3.3.4 Research methodology
1) Sub-study 1: Assessing characteristics of medical tourists VS non-medical tourists and domestic patients
1) Specific research questions
1 How do medical tourists differ from non-medical tourists? In terms of:
1.1 Region of origin
1.2 Gender
1.3 Age
2 How do medical tourists differ from domestic patients? In terms of:
2.1 Gender
2.2 Age
2.3 Type of diseases
2.4 Type of procedures
2.5 Length of stay
2.6 Payment methods
3. How do medical tourists differ between regions? In terms of:
3.1 Gender
3.2 Age
3.3 Type of diseases
3.4 Type of procedures
3.5 Length of stay
3.6 Payment methods
2) Study design and data source
This sub-study conducts a cross sectional survey of all medical tourists who received
medical treatment in the five private hospitals in 2010. It focuses on an explanatory
analysis of the characteristics of medical tourists. To understand key characteristics
of medical tourists obtaining medical services in Thailand and to compare their
differences to domestic Thai private patients and non-medical tourists, two data
67
sources are used. First, medical tourist and domestic Thai patient data are provided
in electronic medical records in five private hospitals. Second, data of non-medical
tourists were provided by the Ministry of Tourism and Sports
2.1 Medical tourist profiles and Thai private patient profiles
A cross-sectional survey of all medical tourists in five hospitals in 2010 was
undertaken. In order to access this data, this study needed ethical approval by each
hospital ethics committee. As Bangkok Hospital, Bangkok Pattaya Hospital,
Bangkok Phuket Hospital and Samitivej Hospitals are part of the same company,
Bangkok Dusit Medical Center (BDMS), the ethical approval process was conducted
only once for these hospitals, and then separately for Bumrungrad hospital. Given
the commercial nature of these organisations, confidentiality was of particular
concern and to ensure that this was maintained, several strategies were established.
First, all information obtained from medical records is linkable but anonymous data.
Each individual identification, such as name, hospital number and admission number
was replaced with a new identification number for the purposes of this study only.
Second, participant identifications were not collected in the survey. Third, all
information given by interviewees was treated confidentially and anonymously. The
process of obtaining ethical approval in Bumrungrad hospital began in May 2011
and approval was given in November 2011, while the process in BDMS began in
May 2011 and approval was given in February 2012.
In each hospital, all patient data, including demographic and service profiles, are
recorded in electronic-based systems. This study used selected variables from all
medical tourists and domestic Thai private patients who visited the five hospitals in
2010. 324,906 records of medical tourists and 2,184,715 records of Thai private
patients were retrieved for analysis.
2.2 International tourist profiles
This study used data on international tourists from “The survey for international
tourist expenditure” conducted by the Ministry of Tourism and Sports (MOTS) in
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2010. MOTS conducts this survey every year in order to monitor important tourism
indicators, such as demographic characteristics, length of stay in Thailand, tourist
spending behaviour and tourism expenditure. Some variables required for this study
concerning international tourists were also retrieved for analysis. 28,013 records of
international tourists surveyed in 2010 were used for analysis.
3) Variables
3.1 Demographic profiles
Three important variables of the demographic profile: country of origin, gender and
age, were collected. These variables were adapted from the survey by MOTS to
enable a comparison between medical tourists and non-medical tourists. Two
variables, gender and age, were also employed for comparison between medical
tourists and Thai patients. This comparison allowed understanding of the different
characteristics of medical tourists compared to non-medical tourists and Thai private
patients in terms of demography.
3.2 Medical service profiles
Five important variables, including diagnosis, type of operation, length of stay in
hospital (in case of admission), total medical expenditure and type of payment were
collected. Variables of type of diagnosis, type of procedure and length of stay in
hospital were deliberately selected as these kinds of variables directly show patients’
problems, the services required and the resources which would be used. These
variables also assist in forecasting the future service demand for overseas patients,
which might affect the domestic resource pool. To standardize patient diagnosis
between hospitals, this study used the 10th revision of the International Classification
of Diseases (ICD-10) for coding diagnosis. To standardize procedures among
hospitals, the ninth revision of the International Classification of Disease, Clinical
modification (ICD-9 CM) was also used for coding procedures.
Meanwhile, variables of total medical expenditure and type of payment were also
purposively selected, as they directly demonstrate how much treatment costs and the
69
methods used for payment, including self-pay, insurance and corporate contract.
Medical expenditure shows the extent of the economic implications of health-related
activities. However, the variable of medical expenditure is employed for analysis in
the next chapter. Payment methods demonstrate more understanding of the way
people are able to subsidize their medical costs when obtaining health services
abroad. These findings could enable policy makers to fill the gaps in the knowledge
necessary to promote the medical tourism industry.
4) Regional selection to be compared
This sub-study attempts to compare not only medical tourists, international tourists
and Thai private patients, but also patients from different regions, providing
information on whether there are differences among the various sub-groups. Seven
regions: Europe, North America, Australia and Oceania, Southeast Asia, the Middle
East, other Asian countries and Africa were selected for comparison (Table 3.2). In
addition, all seven regions were categorized into two groups based on location.
Within-regions refers to all regions in Asia, while long-haul regions refers to all
other regions a.
Table 3.2: Number of medical tourists by region
Number of patients % of total number
1.Europe 14,004 13.52
2.North America 9,481 9.15
3.Australia 3,949 3.81
4.Southeast Asia 14,730 14.22
5. Middle East. 40,554 39.15
6.Other parts of Asia 16.869 16.29
7.Africa 3,957 3,82
Total 103,578 100.00
Source: Medical records from the five hospitals
To understand the key characteristics of medical tourists obtaining medical services
in Thailand and to compare their differences to domestic Thai patients and non-
medical tourists, three databases are needed. Medical tourist and domestic private
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patient data is provided from medical records in the five private hospitals. Regarding
non-medical tourist data, this sub-study used data from MOTS survey.
5) Analytical methods
5.1 Two independent samples T-Test
Two independent samples T-Test is the most commonly used method to evaluate the
differences in means between two groups, where samples are normally distributed.
Though data on the age and the length of stay of medical tourists, international
tourists and Thai private patients were non-normally distributed, the Central Limit
Theorem was applied, as the samples in all compared groups were large enough
[124]. Thus, for numerical variables on age and length of stay in specific question
item 1.4, 2.2 and 2.4, the two independent samples T-Test was employed.
The null hypothesis is that there is no difference of means between two compared
groups, medical tourists VS international tourists and medical tourists VS Thai
private patients. The alternative hypothesis is that there is a difference between the
two compared groups. The significance is tested at 95 confidence intervals.
5.2 The Pearson Chi-square
The Pearson Chi-square is the most commonly used test for significance in the
relationship between categorical variables. Thus, for categorical variables on region,
gender and payment method in specific questions item 1.1, 1.2, 1.3, 2.1, 2.3, 2.4, 2.6,
3.1, 3.3, 3.4 and 3.6 the Pearson chi-square was employed.
The hypothesis is that there is no difference in tested variables between medical
tourists and non-medical tourists/domestic private patients, while the alternative
hypothesis is that there is a difference between the two compared groups. The
significance is tested at 95 confidence intervals.
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5.3 Analysis of variance (ANOVA)
To investigate the difference of means in more than two populations, analysis of
variance (ANOVA) is used. Though a normal distribution of samples is required for
this technique, as mentioned above, the Central Limit Theorem was applied
regarding the substantial number of compared samples. Thus, to compare means of
age and the length of stay among regions and countries of medical tourists in specific
research questions 3.2 and 3.5, ANOVA is employed.
The null hypothesis is that there are no differences of means in tested variables
among regions and countries of medical tourists, while the alternative hypothesis is
the group means are not the same.
2) Sub-study 2: Assessing the expenditures of medical tourists on medical care and tourism revenues
1) Specific research questions
1. Does the tourism spending profile of medical tourists differ from that of non-
medical tourists?
2. Does the tourism spending profile of medical tourists’ companions differ
from that of the companions of non-medical tourists?
3. What are the factors influencing tourism expenditure for medical tourists and
non-medical tourists?
4. Does the medical spending of medical tourists differ from that of Thai
patients?
5. Does the medical spending of medical tourists differ by region?
2) Study design and data sources
This sub-study focuses on an explanatory analysis of expenditure on tourism and
medical elements by medical tourists and their companions. Furthermore, a
comparison with non-medical tourists and Thai private patients is also employed, to
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understand how much they differ from each other. To accomplish this, several data
sources were used. First, the medical expenditures of medical tourists and Thai
private patients are provided from the electronic medical records of the five
hospitals, which are in the same database as referred to in the previous chapter.
Second, tourism expenditure of non-medical tourists is provided by the tourism
expenditure survey of the Ministry of Tourism and Sports, which is from the same
database in previous chapter. These two databases provide data from the year 2010.
Third, in order to assess the tourism expenditure of medical tourists and their
companions, this study conducted a survey in five private hospitals in 2012 (Table
3.3).
Table 3.3: Data sources
Expenditure Group Source
1. Medical expenditures Medical tourists Medical records in 2010
Domestic private patients Medical records in 2010
2. Tourism expenditures Medical tourists and companion s Medical tourist survey in 2012
Non-medical tourists Survey of MOTS in 2010
Medical expenditure is compared between Thai patients and medical tourists to
determine whether they spend differently. Moreover, comparison between source
regions of medical tourists is also employed to demonstrate whether there are
differences in spending among these groups.
In this chapter total expenditure and actual tourism expenditure are separately
analysed. Actual tourism expenditure consists of the expenses from all elements of
tourism, including local transportation, accommodation, food & drink, sight-seeing,
shopping, entertainment and other expenses; medical expense is not included in this
category. Actual tourism expenditure is established in order to compare real spending
on these tourism elements between medical tourists and non-medical tourists. This
allows more insight into how much revenue medical tourists add to the revenue
generated by non-medical tourists. Furthermore, tourism spending profiles are also
analysed. This shows in which categories medical tourists prefer to spend, and
whether these differ from the categories in which non-medical tourists spend.
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2.1 Medical expenditure of medical tourists and Thai private patients
Information on the medical expenditures of medical tourists and Thai private patients
are recorded in patients’ medical records in the five private hospitals. This chapter
employs information on medical expenditures from the medical records in Chapter 4.
Total medical expenditure is the total expenses incurred by each patient for their
medical services. It includes doctors’ fees, drugs, investigations, procedures, room
fees and other related costs. This study uses data from the year 2010; the expenditure
records of 104,830 medical tourists and 497,265 Thai patients were retrieved for
analysis. As there are substantial differences between OP and IP expenses, this
chapter analyses them separately.
2.2 Tourism expenditure of non-medical tourists
To assess the tourism expenditures of non-medical tourists, secondary data on
international tourist expenditures from the MOTS 2010 survey was employed.
Hence, this chapter used the same database mentioned in chapter 4. 28,013 records
of non-medical tourists were employed for analysis.
2.3 Tourism expenditure of medical tourists and their companions
No previous study has specifically examined the tourism expenditure of medical
tourists. To assess this expenditure, and that of these tourists’ companions, a patient
survey was conducted in four of the five selected hospitals; the other hospital did not
wish to participate in this survey.
3) Sample size
To identify a sample size for a survey, three criteria usually need to be specified: the
level of precision, the level of confidence of risk and the degree of variability in the
attributes being measured [125]. The variability of variables in the study is
considered a critical component. In the case of unknown variability, use of data from
previous studies of the same or a similar population is recommended [126].
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However, an appropriate sample size for a survey requires a balance between
precision and cost [127].
As this study aims to assess the average expenditures of medical tourists, the formula
for the sample size for continuous data was applied. The equation used to calculate
sample size was [128]:
n0 = N Z2 σ2
N e2 + Z2 σ2
n0 is the sample size
N is the number of medical tourists in 2010
Z is an interval of confidence
e is the desired level of precision
σ2 is the variance of tourism expenditure of medical tourists
104,830 medical tourists were treated in the five hospitals in 2010. As a standard
deviation (σ) of tourism expenditure of medical tourists has never been studied
before, this survey employed a standard deviation of tourism expenditure from a
survey carried out by the Ministry of Tourism and Sports instead. The standard
deviation of tourism expenditure of non-medical tourists in 2010 was 2,594. A 95%
confidential interval and 5% level of precision were employed in a formula. The
appropriate sample in this survey was 578 patients.
As there were medical tourists from 55 countries visiting the five hospitals, it was
too difficult to collect samples from all countries. Thus, the top 15 countries ranked
by number of patients in 2010 were selected. Medical tourists from fifteen countries
comprised the majority, accounting for 78%, of total medical tourists in 2010. This
study applied a probability-proportional-to-size sampling technique to allocate all
samples into two strata. The first stratum was countries, and the second stratum
hospitals. A simple form of case selection from each stratum was also employed, as
below. The sample size for each country is described in Table 3.4.
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Table 3.4: Sample distribution
Country Samples
1 U.A.E. 151
2 Bangladesh 59
3 USA 55
4 Myanmar 53
5 Oman 50
6 Qatar 37
7 United Kingdom 28
8 Other African countries 27
9 Cambodia 27
10 Australia 24
11 Kuwait 22
12 Japan 14
13 France 12
14 Germany 11
15 Canada 10
Total 580
4) Sampling technique
To achieve representativeness of a population, an appropriate sampling technique is
needed. Medical tourists in the study were recruited by a consecutive case selection,
such that all patients had the same probability of selection. With respect to ethics, all
patients had to agree to participate in this study by signing a consent form. In the
case of out-patient services, interviews were conducted at the cashier unit before
patients left the hospital. In the case of in-patients, interviews were conducted before
patients left the hospital. Interviewers collected all cases until they reached the
required number in each hospital. The survey was conducted between June and
September 2012. Due to time constraints, data was collected from 293 patients,
accounting for 50.7% of the total desired sample. It seemed that most respondents
fell into low-income groups; well-off patients were difficult to approach. Thus, the
survey results are unlikely to represent the full scale of medical tourist experiences
across the five hospitals. However, this number of patients is the largest sample
among any survey on medical tourists conducted to date, and the bias towards to
low-income groups may provide a minimum foundation to identify the likely
revenues generated for the tourism sector, and the private hospitals. Differences in
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case-mix between income groups may also lead to some misrepresentation of the full
picture, but it is less straightforward to predict the direction this may take.
5) Questionnaire
To assess the tourism expenditures of medical tourists, a questionnaire was adapted
from the one used by MOTS in a survey of the tourism expenditure of international
tourists. This questionnaire was chosen because it enabled a comparison between the
two sets of results, and because it is considered a standard survey. However, some
questions were changed to make them more appropriate and relevant to this study.
The adapted questionnaire was piloted before starting the survey in order to
eliminate inconsistencies.
The questionnaire was designed to elicit general demographic and expenditure
information concerning medical tourists, their relatives and companions. To
determine the personal profiles, the questionnaire included key questions on (1)
country of origin, (2) gender, (3) age, (4) occupation, (5) personal income and (6)
length of stay in Thailand. The main categories of tourism spending profiles are (1)
local transportation, (2) accommodation, (3) food & drink, (4) sightseeing (domestic
tours), (5) shopping, (6) entertainment, leisure & sports activities and (7) other
expenses. A question on the number of companions was also included. Questions on
demography and tourism spending profiles were purposely selected in order to be
compared with variables from the MOTS survey. Variables in tourism spending
profiles allow understanding of the spending behaviour of medical tourists and their
companions and whether they spend differently from non-medical tourists.
To elicit whether healthcare was the main reason for medical tourists to visit
Thailand, or if they came as tourists but added some healthcare to their trip, a
specific question on this issue was included in the questionnaire. To illustrate the
importance of the medical element of a trip, all participants were asked a question on
the relationship between the medical treatment and the purpose their visit; to answer
it, participants had to choose the most appropriate statement from three options: 1)
medical treatment was the only purpose, 2) medical treatment was the main purpose
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and 3) medical treatment was added after planning a visit to Thailand. The
questionnaire was available in three languages: English, Arabic and Japanese, in
accordance with the fifteen source countries in the survey. All three languages
versions of the questionnaire are included in Annex 3.
To avoid any possibility of incomplete information which might occur if the
questionnaire was self-administered, the questionnaire was used as a guideline for
interviewers to interview patients. Interviewers were selected from nurses and
translators who were working in the hospitals. To standardize the interviewing skills
and minimize data-collecting errors, all interviewers taking part in this survey
attended a half-day training course in data collection, convened by the primary
investigator of this study. Information on tourism expenses were obtained by asking
patients to recall all their spending in each category. To enhance data accuracy,
experts in the MOTS survey were consulted for technical support; this survey
employed the same guidelines when asking about tourism expenditures in each
category of the MOTS survey.
6) Variables
6.1 Medical expenditure
Medical expenditure was defined as the actual invoice patients paid upon leaving
hospital. In this chapter it is analysed under two categories; out-patient expense and
in-patient expense, as there are considerable differences in the resources needed in
each category, resulting in significant differences in expense. Out-patient and in-
patient expenditure is defined as expenditure per patient, not per visit or per
admission; the annual expenditure by each individual for both out-patient and in-
patient services.
6.2 Tourism expenditure
The main categories of tourism spending profiles are (1) local transportation, (2)
accommodation, (3) food & drink, (4) sightseeing (domestic tours), (5) shopping, (6)
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entertainment, leisure and sports activities, and (7) any other expenses (Table 3.5).
Medical tourists were asked how much they spent in each category by all types of
payment; cash, credit cards, debit cards and any other methods. They were also
asked about the expenditure of their companions.
Table 3.5: Key variables on tourism expenditures
Profile Variables
Personal profiles 1) Country of origin
2) Gender
3) Age
4) Occupation
5) Personal income
6) Length of stay in Thailand
Spending profiles 1) Local transportation
2) Accommodation
3) Food & Beverage
4) Sightseeing
5) Shopping
6) Entertainment & Leisure
7) Others
7) Data analysis
This section aims to analyse the differences between the expenditures of medical
tourists, non-medical tourists and domestic Thai patients. A comparative approach is
used for data analysis in this sub-study.
7.1 T- Test analysis for specific research questions 1,2,4 and 5
Two independent samples T-Test is the most commonly used method to evaluate the
differences in means between two groups, where samples are normally distributed.
Though data on medical and tourism expenditure are non-normally distributed, the
Central Limit Theorem is applied, as the samples in all the compared groups are big
enough [124]. The null hypothesis is that there is no difference in expenditures
between medical tourists and their companions, and non-medical tourists and
domestic private patients. The alternative hypothesis is that there is a difference
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between the two compared groups. The significance is tested at 95 confidence
intervals.
7.2 Multiple regression model for specific research question 3
Tourism has been considered an important industry in generating national income. Its
economic impact is felt from small communities to the destination country as a
whole [129]. Tourism, or travel, expenditure consists of all the expenses incurred
while tourists stay in the destination area. Tourism expenditure is the main
component of the travel economic impact model (TEIM), as it provides information
to measure the economic impact of tourism [130]. In detail, it includes the cost of
accommodation, local transportation, food & drink, sight-seeing tours,
entertainment, shopping and the purchase of souvenirs. The factors which influence
tourism expenditure are important to travel organizers and tourism policy makers
[131], enabling marketing to specific groups in order to increase tourist spending and
therefore revenue to destination countries [132]. In essence, factors influencing
tourism expenditure are divided into two main groups: socio-economic and travel-
related variables. Socio-economic variables include age, gender, income, and
occupation, while travel-related variables include such elements as number of travel
companions and length of stay. Marcussen, Cael H. conducted a meta-analysis of
factors affected tourism spending and identified 18 significant variables [133]. These
are: type of accommodation, length of stay, travel party size, destination, travel
distance, origin market, travel purpose, mode of transportation, activities, age,
packaging, income, purchase channel, information sources, gender, first time VS
repeated visit, motivation and season [133].
In order to assess what factors influence tourism expenditures in Thailand, a model
of total tourism spending as a function of factors was developed. Regarding data
available, the variables postulated to affect this spending are: type of tourist, region
of origin, gender, age, personal income and length of stay in Thailand. The variable
on type of patients is included in the equation in order to determine whether being a
medical tourist influences tourism expense. A normality of tourism expenditure was
tested and was found to be not normally distributed. Thus, the natural log of tourism
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expenditure is used and ordinary least squares (OLS) is also employed. All variables
are combined in a multiple regression model as illustrated below:
Where Exp is the tourism spending per day and - are the factors affecting
spending, and their detail is demonstrated in Table 3.6. All six variables were
categorized into attributes as described in Table 3.6. A multiple regression was used
for data analysis.
Table 3.6: Explanation of each factor employed in a spending function
Factor Meaning Attributes
X1 Type of tourist 1. Non-medical tourists
2. Medical tourists
X2 Region of origin 1. Long-haul
2. Within
X3 Gender 1. Male
2. Female
X4 Age 1. Less than 25
2. 25-34
3. 35-44
4. 45-54
5. 55-64
6. More than 65
X5 Annual personal income 1. Less than 20,000 USD
2. 20,000-39,999 USD
3. 40,000-59,999 USD
4. 60,000-79,999 USD
5. More than 80,000 USD
X6 Length of stay 1. 1-3 days
2. 4-7 days
3. 8-14 days
4. 15-30 days
5. More than 30 days
8) Currency exchange
All expenditures in this chapter are reported in the Thai Baht currency. To compare
the figures to other international currencies, this study employed the 2013 exchange
1X 6X
eXXXXXLnExp 4 55433221 1 6 X 6
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rate of one US dollar to 30 Thai Baht, one Euro to 40 Thai Baht and one Pound
Sterling to 50 Thai Baht.
3) Sub-study 3: Assessing the impact of medical tourists on private hospitals
1) Specific research questions
1. Are medical tourists treated differently from domestic private patients? If so,
why?
2. How are the resources required for medical tourists obtained? And on what
basis?
3. How are revenues from medical tourists allocated?
The previous sub-study provided quantitative data on the impact of medical tourists
on the national economy, through an understanding of their spending on medical and
tourism elements of their travel. However, it could not provide information on the
impact on the domestic health system, which is recognized as an important
component in any conclusion on overall impact; in order to answer the three specific
research questions above, alternative methods were required. Specifically,
information was obtained from interviews in order to understand the medical tourism
business in private hospitals, and also its impact on the domestic health system,
specifically on private hospitals.
2) Study design and data source
Interviews
Qualitative research relied on semi-structured interviews. An interview is a widely
used approach for producing information in qualitative work [134]. It is a dialogue
between a researcher and a participant which directly elicits responses to the study’s
key questions. The qualitative interview approach explores participants’ views
compared to those of others, to establish an understanding of the issues being
studied. Semi-structured interviews are guided by an Interview Guide covering the
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key themes the interviewer seeks to explore. Compared to structured interviews or
surveys, it usually employs open-ended questions, to allow participants to express
their views without being influenced by the prior assumptions of an interviewer,
whose social interaction skills should include building rapport, listening,
encouraging interviewees to continue and being friendly, in order to encourage
participation [135]. Interviews can range from a structured interview: a conversation
with strictly ordered questions, to an informal interview: a loose and incidental
conversation. Structured interviews provide tightly controlled information with
answers which can be compared to those of other participants, while informal
interviews produce more diverse information. This section employs a semi-
structured interview, which is somewhere between these two approaches. A semi-
structured interview allows a researcher to establish guide topics included in the
study, and a participant can then describe their experiences and perceptions freely
and flexibly with regard to these topics.
In qualitative research, the number of respondents participating depends on the aims
of the study. It differs from quantitative research in which sample size can be
calculated according to population characteristics and levels of confidence. Each
sample in quantitative research has an equal chance of being selected; this is
probability sampling; most qualitative studies employ purposive sampling, in which
participants with the potential to provide rich and useful information are purposely
selected. Various sampling strategies are employed in purposive sampling, including
deviant-case sampling, typical-case sampling and snowball sampling [135]. In some
situations, political considerations are taken into account in sample selection in order
to accomplish the aims of the study. In theoretical sampling as part of a grounded
theory approach, an appropriate number of samples depends on data saturation – a
stage where no new information is being generated. However, in practical terms, it is
difficult to meet these criteria. With a well-designed and specific research question,
most qualitative researchers suggest no new information will appear after
interviewing 20 participants of one category. Participants should be selected from
various groups, for example defined by gender, age, race, role in society and other
categories according to the aims of the study, to ensure coverage of all aspects of the
required information.
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To ensure quality in qualitative research, good practice to increase reliability and
validity is required [135]. Examples of good practice are transparency of
methodology, identifying a clear analysis procedure, identifying how coding has
been developed and a clear sampling method. To maximize validity, researchers
should not interpret information according to their own presumptions. Investigating
deviant information, rather than disregarding it and reporting only commonly-held
views, would increase the validity of data [136]. Taking findings back to participants
for their approval is a good way to ensure respondent validity. Reliability is also
important in qualitative work; the same research work should produce similar
themes. Accurate note taking, correct transcription and regular discussion coding
with field colleagues are ways to increase reliability. Comparison among cases
within the same data set ensures data regularity, while comparison data within a case
provides contextual meanings of the information [135].
Reflexivity is another concern in a qualitative work. Reflexivity refers to the
researcher’s awareness that they can influence the research processes. Reflexivity is
important in the processes of both data collection and data analysis [137]. This is
because researchers are often influenced by their professional backgrounds,
experiences and pre-perceived ideas during data interpretation. To be reflexive,
researchers are encouraged to reflect on their interpretations. They should be
reminded that the validity of their interpretation is dependent on being able to
demonstrate how these interpretations were reached [138].
3) Participants
For sub-study 3, participants were purposively selected according to their roles in
private hospitals to ensure adequate information was obtained to answer specific
research questions. Participants were classified into two main groups, hospital
executives and service providers. Hospital executives were considered to be best
placed to provide information on hospital policy on serving medical tourists and
other international patients; such as whether they have specific policies with regard
to differences between foreign patients and local patients, how they obtain resources
to serve foreign demand and how they allocate the revenues generated by foreign
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patients (Table 3.7). Hospital executives include chief executive officers (CEO),
hospital directors, medical directors, human resource directors and marketing
directors. Chief executive officers and hospital directors are considered the best key
informants to provide specific information on overall hospital policy and resource
allocation. Medical directors, being responsible for managing physicians and dentists
in most private hospitals, were selected to provide specific information on these two
professions, while human resource directors were key informants on managing other
health professions and office staff. Marketing directors were selected to provide
information on overall hospital policy, in particular that concerning overseas
customers, and how hospitals are coping with the emergence of foreign demand,
particularly in terms of resource allocation. Representatives of each of these
positions in each hospital were selected at the start of data collection.
Service providers were selected as participants in order to provide information on
how services delivered to medical tourists differ from how they are delivered to
Thais, Doctors and nurses were purposively selected for this category as they are in
the best position to provide this information (Table 3.7). Doctors were asked to
provide specific information on medical treatment, while nurses were asked to give
information on nursing care and peripheral services not included in direct medical
care. To ensure enough rich information, service providers had to have enough
experience in servicing foreign patients, particularly in terms of how long they had
been delivering these services. To ensure enough diversity of information, they were
chosen from a variety of hospital departments. Thus, specific criteria for selection
were established; details were as follows:
1. They had to be full-time staff serving both Thai and international patients
2. They should have worked in the same hospital for at least five year
3. They had to come from different departments.
At each hospital, doctors and nurses who met these criteria were selected as
participants. At the beginning of the interview phase, five doctors and five nurses in
each hospital were initially required, although if the information elicited did not
reach saturation point, more participants were recruited.
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Table 3.7: Core information and key informants
Core information required Key informants
Hospital executives Service provider
1 Overall hospital policy towards international
patients X
2 Source of hospital resources X
3 Resource allocation within hospital (overseas
VS domestic) X x
4 Revenue allocation X
5 Difference in delivery of services x
Four hospitals, Bumrungrad Hospital, Bangkok Hospital, Bangkok Pattaya Hospital
and Bangkok Phuket Hospital allowed interviews to be conducted in their hospitals;
only one, Samitivej Hospital, refused permission. However, this hospital was also
part of the Bangkok Dusit Medical Service Public Company, Limited (BDMS)
which included Bangkok Hospital, Bangkok Pattaya Hospital and Bangkok Phuket
Hospital, and they shared common policies in patient service. 18 hospital executives
(2 CEOs, 4 hospital directors, 4 medical directors, 4 human resource directors and 4
marketing directors), 20 doctors, and 20 nurses, were initially selected from four
private hospitals. Eventually, however, 15 hospital executives, 12 doctors and 16
nurses were interviewed (Figure 3.4).
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Figure 3.4: Cascade of participants in four private hospitals
The sampling process presents some imbalances in the distribution of participants.
First, no hospital chief executive officers (CEOs) participated in this study as they
were unavailable for interview during the data collection period. There were actually
only two CEOs between the four hospitals, as Bangkok, Bangkok Pattaya and
Bangkok Phuket Hospital share the same CEO. Secondly, there are very few hospital
executives representing each position. However, they engage at a high level of
decision making on hospital policies and they are members of the hospital executive
board. In terms of time limitations during the data collection period, 12 doctors
participated in interviews. No new information was forthcoming towards the latter
interviews, and the level of detail and richness of information from each interview
was considered sufficient for the purposes of analysis. Sixteen nurses from four
hospitals were also interviewed. As no new information emerged in the later
interviews, further interviews were cancelled.
Nurses 16
Total
participants 43
Hospital Executives
15
Service Providers
28
Chief Executive Officer
0
Hospital director 4
Medical director 3
Human resource director
4
Marketing director 4
Doctors 12
87
The interviews were conducted from May to August, 2012. Appointments for
interviews with all participants were made in advance; these interviews took place in
the hospital where the interviewee worked. To ensure privacy and confidentiality,
interviews with hospital executives were conducted in their offices, and those with
doctors and nurses in separate rooms. As the primary investigator is a government
officer and also a medical doctor, it was challenging to remain reflexive throughout
the processes of data collection and analysis. However, he tried to avoid guiding the
answers, and to interpret the data as provided, without allowing his own experience
to influence the analysis, as outlined earlier.
Prior to each interview, participants were informed about the background and
objectives of the study and asked to read and sign the consent form. At the beginning
of the interview, general questions on participants’ responsibilities and an overall
picture of the hospital were asked, to familiarise the process, followed by topic-guide
questions in relation to specific research questions. During each interview, the
primary investigator used open-ended questions without any presumptions, to allow
free responses. To increase validity, information was always triangulated with
information from prior participants and other data sources. Before starting the
interview, literature and documents relating to servicing patients in private hospitals
were reviewed to develop an initial understanding of the context of private hospitals.
Informal discussions with the primary investigator’s contacts practising in private
hospitals also helped to set the scene. Deviant information was deliberately
investigated by asking for more detail and re-checking understanding between
participant and primary investigator. Although hospital executives tended to provide
good, relevant information, it was still triangulated with service providers’
information for examples of real practice. Service providers in this study were
purposively selected by the hospitals themselves, which may have led to a selection
bias, as they tended to give a positive perspective on serving foreign patients. During
the interview, however, both positive and negative views of serving foreigners
emerged from service providers participating in the study. Furthermore, it was found
that some of the information they provided differed from that of the executives. The
interviews lasted approximately one hour for hospital executives and 45 minutes for
service providers.
88
All participants’ responses were recorded on digital tapes, which were then
transcribed. All participants were Thai, with one exception, so all transcriptions but
one were in the Thai language.
4) Guide questions
Interviews were conducted in accordance with prepared agendas which included
guide topics as prompts for asking the questions. Guide topics were aimed directly
towards the three specific research questions of this study. Questions for hospital
executives and service providers were different; those for hospital executives
focused on hospital policies concerning foreign patients, routes for seeking
resources, serving foreigners and how revenues were allocated; those for service
providers emphasized how foreign patients were treated and whether there were any
differences in services delivered to Thais and foreigners. The guide questions are
described in Annex 5.
5) Data analysis
This study adopted a framework approach for data analysis. Framework analysis is a
popular approach in health and social science research for policy formulation [135].
It is “a content analysis method which involves summarizing and classifying data
within a thematic framework” [135]; hence more practical for generating policy-
orientated findings. All data recorded in interviews were transcribed into text. Key
topics related to the three specific research questions, such as type of services (direct
medical services and peripheral services) and type of resources (infrastructure,
medical equipment and human resources for health), were set up as the framework
for analysis. Data was coded and managed by themes focusing each topic. Themes
were categorized by comparing each participant with others. They were then
interpreted to arrive at the conclusions. Information from medical record analysis in
the previous chapter was used to triangulate interview information to increase the
validity of the study. To further increase validity during data analysis, all information
was interpreted based solely on the data as provided, and was double-checked
89
through conversations with supervisors to ensure that the primary investigator’s prior
experience and views influenced interpretation as little as possible, in line with the
need for reflexivity as outlined earlier.
In the result section, quotes are annotated by a hospital code and their role in a
hospital. The first alphabetical code (H) refers to the hospital - H1, H2, H3 and H4
refer to Bumrungrad, Bangkok, Bangkok Pattaya and Bangkok Phuket Hospital
respectively (Table 3.8). The second alphabetical code refers to the hospital role – E
as hospital executive, M as medical doctor and N as nurse (Table 3.8).
Table 38: Participant code
3.4 Ethical consideration
3.4.1 Ethical approval process
An ethical application was submitted to the ethical committee of the London School
of Hygiene and Tropical Medicine (LSHTM) and to the ethical committees of 2
private hospitals; Bumrungrad International Hospital and Bangkok Hospital. As
Samitivej Hospital, Bangkok Pattaya Hospital and Bangkok Phuket Hospital are part
of the same company as Bangkok Hospital, there was no need for a separate
application. The study was approved by all the hospitals involved before the start of
the data collection process.
Code Definition
First alphabetical
code
H1 Bumrungrad Hospital
H2 Bangkok Hospital
H3 Bangkok Pattaya Hospital
H4 Bangkok Phuket Hospital
Second alphabetical
code
Ex Hospital executive
Mx Medical doctor
Nx Nurse
90
3.4.2 Consent
Informed consent was required for medical tourists participating in Sub-study 2 to
ensure their voluntary participation. Likewise, regarding the interview process in
Sub-study 3, informed consent was also obtained from all interviewees, which
included giving them a brief introduction, and details of the data collection strategy
and the overall objectives of the study. Before each interview, participants were
asked to permit the use of a digital tape recorder; if this was refused, the primary
investigator used hand-written notes.
3.4.3 Confidentiality and anonymity
Anonymity and confidentiality were assured. All patient names and other
identification, such as hospital number and admission number, in the medical records
were changed to a specific code for this study to ensure that the primary investigator
could not trace any participant. The study provided participants with the option to be
identified or to remain anonymous. Names and other identifications were removed or
changed to maintain confidentiality. All information concerning patients and
hospitals will be kept securely by the primary investigator for 10 year, following the
confidentiality policy of the London School of Hygiene and Tropical Medicine.
91
Chapter Four
Assessing characteristics of medical tourists
VS non-medical tourists and Thai private patients
92
Chapter 4 Assessing the characteristics of medical tourists VS non-
medical tourists and Thai private patients
It is estimated that 4 million international patients travel abroad every year, and of
these, Thailand serves between 1.2 and 1.4 million [74]. In essence, information on
international patients is always presented in aggregate. Moreover, most national data
sources are highly heterogeneous, derived from different sources and using different
definitions [77]. The reported number often includes expatriates and general tourists
who require medical care while travelling [5]. In addition, some wellness services
such as spas and massage may also be included.
In Thailand, an annual survey of international patients in private hospitals is carried
out by the Department of Export Promotion, Ministry of Commerce [74]. Aggregate
numbers of international patients, including their country of origin, are collected
from each hospital serving these customers. However, this aggregated information
provides little detail on other characteristics and service behaviours. Moreover, this
information does not differentiate between patients who went abroad for medical
services and expatriates and general tourists who happened to fall ill during their
visit.
Consequently, there is a great lack of information concerning the characteristics of
medical tourists, such as their demographic profiles, which would be required to
analyze whether they differ from non-medical tourists, and enable us to understand
whether there is something ‘unique’ about medical tourists. In terms of the medical
care element, it is also important to understand their medical service profiles and
investigate whether they represent different characteristics from domestic Thai
private patients; again, establishing what may be ‘unique’ about medical tourists.
This new knowledge would allow hospital executives and policy makers in both
health and trade sectors to establish effective resource-utilization and market plans.
By comparing demographic profiles, it should be possible to understand if there are
93
just general tourists who attach medical care to their trip, or if they are a specific
type of foreigner. This would allow trade policy makers to bring tourism activities to
these foreign patients, or to activate medical services for general international
tourists. Comparing medical service profiles allows understanding of whether these
patients visit hospital for the same services as Thais, if they compete for resources
with local private patients, or if they receive special services that differ from those
provided to Thais.
4.1 Aim and specific research questions
The aim of this chapter is to assess the characteristics of medical tourists, non-
medical tourists and Thai private patients. To do this several specific research
questions are addressed:
1 How do medical tourists differ from non-medical tourists? In terms of:
Region of origin
1.1 Gender
1.2 Age
2 How do medical tourists differ from domestic patients? In terms of:
2.1 Gender
2.2 Age
2.3 Types of diseases
2.4 Types of procedures
2.5 Length of stay
2.6 Payment methods
3. How do medical tourists differ between regions? In terms of:
3.1 Gender
3.2 Age
3.3 Types of diseases
3.4 Types of procedures
3.5 Length of stay
3.6 Payment methods
94
Results
This section aims to assess the characteristics of medical tourists, by comparing them
from many aspects with non-medical tourists and Thai private patients. This allows
understanding of whether medical tourists are just tourists who receive medical care,
or whether they differ significantly in other ways. Furthermore, if there are
differences, how this information could help the trade and tourism sectors to modify
their marketing strategies, and the health sector to prepare the necessary health
resources.
4.2 Comparison between medical tourists and non-medical tourists
Medical tourists have several different characteristics from non-medical tourists.
They mostly come from the Middle East, Southeast Asia, Europe and South Asia
while Southeast Asia, Europe and East Asia have the key market-share in non-
medical tourists. In terms of gender, men are in the majority in both medical tourist
and non-medical tourist categories. Medical tourists also tend to be older than non-
medical tourists.
1. Numbers
In 2010, 236,885 international patients received medical services in the five private
hospitals involved in this study, in the course of approximately 911,913 visits. In
terms of numbers of patients, medical tourists are the largest group, accounting for
44.3% of the total. This was followed by foreigners living in Thailand (expatriates)
and then by sick tourists: international tourists who fall ill while travelling in
Thailand (Table 4.4). One patient may visit a hospital on more than one occasion. In
terms of visits, the expatriates group is the largest, accounting for 39%, followed by
medical tourists (35%) and sick tourists (25%). As expatriates are people living in
Thailand, they tend to visit hospital more frequently than other groups, accounting
for 4.80 visits per patient per year, while medical tourists visited the least,
accounting for 3.10 visits per patient per year (Table 4.1).
95
Table 4.1: Number of international patients and visits by type of patient
Patients Visit Average visits per year
Frequency % Frequency %
Medical tourists 104,830 44.3 324,906 35.6 3.10
Expatriates 74,063 31.3 355,687 39.0 4.80
Being ill tourists 57,992 24.5 231,320 25.4 3.99
Total 236,885 100.0 911,913 100.0 3.85
2. Region
There are significant differences between medical tourists and non-medical tourists
in terms of their region of origin. The Middle East, Southeast Asia, Europe and
South Asia were key origins for medical tourists, while Southeast Asia, Europe and
East Asia tended to be the point of origin of non-medical tourists. Patients from the
Middle East were the largest group among medical tourists, accounting for almost
40%, whereas they comprised only 3.6% of international tourists (Table 4.2). In
contrast, the largest group of non-medical tourists came from Southeast Asia,
accounting for 28.5%. Patient numbers from Southeast Asia were still comparatively
large, ranking second, accounting for 14.1%. Europe was the key player among both
medical and non-medical tourists, representing the largest group of those from long-
haul travel. They ranked third in terms of number, accounting for 13.4%; non-
medical tourists from Europe were still the largest group among tourists from
international origins. They ranked second in terms of number, accounting for 27.9%.
“Regional effect” influenced the travel choices of both medical tourists and non-
medical tourists in Thailand. Medical tourists tended to have travelled from within-
region rather than from out-of-region: approximately 70% and 30% respectively,
whereas 60% of non-medical tourists came from within-region and 40% from out-of-
region
96
Table 4.2: Regional distribution between medical tourists and non-medical tourists
Rank in medical tourist
Medical tourists Non-medical tourists Rank in
non-medical tourist
Number % Number %
1 Middle East 40,554 38.7 569,334 3.6 7
2 Southeast Asia 14,730 14.1 4,534,235 28.5 1
3 Europe 14,004 13.4 4,442,375 27.9 2
4 South Asia 12,703 12.1 995,321 6.2 4
5 North America 9,481 9.0 844,644 5.3 5
6 East Asia 4,166 4.0 3,632,929 22.8 3
7 Africa 3,957 3.8 127,930 .8 8
8 Australia 3,949 3.8 789,632 5.0 6
9 Unknown 1,252 1.2 0 .0
10 Other region 34 .0 0 .0
Total 104,830 100.0 15,936,400 100.0
In terms of country of origin, the pattern of medical tourists differs from that of non-
medical tourists. The top 10 countries of origin for medical tourists were those in the
Middle East, Southeast Asia and Europe (Table 4.3). Most of these, except the USA,
the UK and Australia represented a very small proportion of the total numbers of
non-medical tourists. The largest number of medical tourists in Thailand in 2010
came from the UAE, accounting for 20.6%, while only 0.66% of non-medical
tourists came from this country (Table 4.3). On the other hand, most of the top10
countries of non-medical tourists were the source of a very small proportion of
medical tourists. The largest number of non-medical tourists, 13%, came from
Malaysia, while only 0.4% of medical tourists came from there. The UK, the USA
and Australia were represented in the top 10 of both medical and non-medical
tourists.
In summary, the characteristics of medical tourists and non-medical tourists in terms
of region and country of origin were comparatively different. The Middle East,
Southeast Asia, Europe and South Asia played the key roles in supplying medical
tourists, whereas Southeast Asia, Europe and East Asia dominated among non-
medical tourists. In terms of country, countries from the Middle East dominate in the
top 10 group of medical tourists and countries from Southeast Asia and East Asia
97
dominate in the group non-medical tourists; the UK, USA and Australia dominate in
both medical and non-medical tourists.
98
Table 4.3: Countries of origin of medical tourists compared to those of non-medical tourists
Rank in
medical
tourists
Country Medical tourists Non-medical tourists Rank in non-
medical tourist Count % Count %
1 U.A.E. 21,567 20.6 105,162 0.66 31
2 Bangladesh 8,442 8.1 68,081 0.43 38
3 USA 7,854 7.5 611,792 3.84 10
4 Myanmar 7,569 7.2 90,179 0.57 33
5 Oman 7,096 6.8 281,706 1.77 19
6 Qatar 5,212 5.0 **
7 United Kingdom 3,935 3.8 810,727 5.09 4
8 Other African countries 3,857 3.7 70,830 0.44 37
9 Cambodia 3,836 3.7 146,274 0.92 28
10 Australia 3,359 3.2 698,046 4.38 8
11 Kuwait 3,159 3.0 41,224 0.26 44
12 Japan 1,994 1.9 993,674 6.24 3
13 France 1,742 1.7 461,670 2.90 13
14 Germany 1,545 1.5 606,874 3.81 11
15 Canada 1,473 1.4 168,393 1.06 23
16 Other 1,343 1.3 **
17 Bahrain 1,165 1.1 **
18 China 1,127 1.1 1,122,219 7.04 2
19 Other countries in South
Asia 1,067 1.0 23,339 0.15 48
20 Other European
countries 952 0.9 373,534 2.34 32
21 Sweden 919 0.9 355,214 2.23 16
22 India 915 0.9 760,371 4.77 6
23 Netherland 903 0.9 196,994 1.24 22
24 Other countries in the
Middle East 884 0.8 **
25 Switzerland 805 0.8 155,761 0.98 25
26 Vietnam 710 0.7 380,368 2.39 14
27 Italy 644 0.6 168,203 1.06 24
28 Singapore 613 0.6 603,538 3.79 12
29 Indonesia 592 0.6 286,072 1.80 18
30 New Zealand 566 0.5 89,364 0.56 35
31 Nepal 545 0.5 28,621 0.18 46
32 Denmark 539 0.5 152,398 0.96 26
33 Norway 520 0.5 132,108 0.83 29
34 Philippines 506 0.5 246,430 1.55 20
35 Hong Kong 471 0.4 316,476 1.99 17
36 Iran 468 0.4 **
37 Russia 461 0.4 644,678 4.05 9
38 Saudi Arabia 439 0.4 8,463 0.05 52
39 Laos 437 0.4 715,345 4.49 7
40 South Korea 403 0.4 805,445 5.05 5
99
Table 4.3: Countries of origin of medical tourists compared to those of non-medical tourists
(continued)
Rank in
medical
tourists
Country Medical tourists Non-medical tourists Rank in non-
medical tourist Count % Count %
41 Malaysia 394 0.4 2,058,956 12.92 1
42 Pakistan 337 0.3 65,171 0.41 40
43 Egypt 336 0.3 16,729 0.10 50
44 Finland 287 0.3 146,946 0.92 27
45 Other American
countries 286 0.3 64,459 0.40 45
46 Belgium 260 0.2 80,000 0.50 36
47 Israel 228 0.2 116,050 0.73 30
48 Austria 191 0.2 90,026 0.56 34
49 Spain 170 0.2 67,242 0.42 39
50 Taiwan 129 0.1 369,220 2.32 15
51 Sri Lanka 110 0.1 49,738 0.31 43
52 South Africa 103 0.1 57,100 0.36 42
53 Brunei 66 0.1 7,073 0.04 53
54 Other countries in
Australia 24 0.0 2,222 0.01 54
55 Other countries in East
Asia 23 0.0 25,895 0.16 47
Total 104,830 100 15,936,400 100
Note: ** Other countries from Middle East regions
Statistical analysis
From table 4.2 and table 4.3, Pearson’s Chi-square test was employed to find out
whether there was any difference in region and country distribution between medical
tourists and non-medical tourists. A statistically significant difference in regional
distribution (p value < 0.0001) and in country distribution (p value < 0.0001) was
found between medical tourists and non-medical tourists.
3. Gender
Overall, men dominate in both medical and non-medical tourist categories,
accounting for 58% and 60% of the respective totals (Table 4.4). Men dominate in all
regional categories among non-medical tourists. Men dominate among all regions for
medical tourists except for Australia and Southeast Asia (Table 4.5).
100
Table 4.4: Gender comparison between medical tourists and non-medical tourists
Medical tourists Non-medical tourists
Count % Count %
Male 60,828 58.0 16,983 60.6
Female 43,982 42.0 11,030 41.4
Total 104,810 100 28,013 100
Table 4.5: Comparison of gender between medical and non-medical tourists
Medical tourists Non-medical tourists
Male % Female % Male % Female %
Europe 9,282 66.3 4,717 33.7 3,906 57.3 2,909 42.7
North America 6,112 64.5 3,367 35.5 1,212 57.4 898 42.6
Australia 2,045 51.8 1,904 48.2 916 59.1 635 40.9
Southeast Asia 6,234 42.3 8,491 57.7 3,545 57.1 2,665 42.9
Middle East 24,450 60.3 16,103 39.7 1,211 70.4 508 29.6
Other Asia 9,711 57.6 7,154 42.4 5,833 64.5 3,216 35.5
Africa 2,319 58.6 1,638 41.4 360 64.4 199 35.6
Overall 60,828 58.0 43,982 42.0 16,983 60.6 11,030 41.4
Statistical analysis
From table 4.4, Pearson’s Chi-square test was employed to find out whether there
was any difference in gender distribution between medical and non-medical tourists.
A statistically significant difference in gender distribution (p value < 0.0001) was
found between medical and non-medical tourists.
4. Age
Overall, medical tourists tended to be older than non-medical tourists. The largest
group of medical tourists was in the age group 35-44, accounting for 22%, whereas
the largest group of non-medical tourists was in the younger age group 25-34,
accounting for almost 39% (Table 4.6). Moreover, the number of medical tourists
aged over 45 is slightly higher than the number of non-medical tourists in this age
group. Male medical tourists tended to be older than female; almost 50% of the men
in this category were aged over 45, as opposed to 40% of the women. Similarly,
101
female non-medical tourists tended to be younger than male: almost 70% of the
women in this category were under 35, as opposed to 50% of men.
Table 4.6: Age distribution between medical tourists and non-medical tourists
Medical tourists Non-medical tourists
Count % Count %
Male Less than 25 7,624 12.5 2,427 14.3
25-34 10,415 17.1 6,108 36.0
35-44 13,366 22.0 4,717 27.8
45-54 13,469 22.1 2,561 15.1
55-64 9,892 16.3 906 5.3
Over 65 6,050 9.9 264 1.6
Total 60,816 100.0 16,983 100.0
Female Less than 25 7,711 17.5 2,782 25.2
25-34 9,406 21.4 4,723 42.8
35-44 9,425 21.4 2,017 18.3
45-54 8,409 19.1 1,070 9.7
55-64 5,792 13.2 381 3.5
Over 65 3,233 7.4 57 0.5
Total 43,976 100.0 11,030 100.0
Overall Less than 25 15,338 14.6 5,209 18.6
25-34 19,822 18.9 10,831 38.7
35-44 22,796 21.7 6,734 24.0
45-54 21,882 20.9 3,631 13.0
55-64 15,689 15.0 1,287 4.6
Over 65 9,285 8.9 321 1.1
Total 104,812 100.0 28,013 100.0
Statistical analysis
From table 4.6, Pearson’s Chi-square test was employed to find out whether there
was any difference in age distribution between medical and non-medical tourists
overall. A statistically significant difference in age distribution (p value < 0.0001)
was found between medical and non-medical tourists.
In summary, it is apparent that medical tourists differ from non-medical tourists in
many ways. Patients from the Middle East region represent the largest market share
in medical tourists, while there are very few non-medical tourists from this region. In
contrast, tourists from East Asia visit Thailand a lot, but not as patients. Meanwhile,
102
people from Southeast Asia and Europe are common visitors as both medical tourists
and non-medical tourists. Because of the increase in illness associated with age,
medical tourists tend to be older while non-medical tourists, the back-packing
generation, are significantly younger.
4.3 Comparison between medical tourists and Thai private patients
Thai patients dominate in the five private hospitals in this study, while international
patients represent only 32%. However, of all international patients, medical tourists
are the largest group, accounting for 44%. Medical tourists show characteristics
which differentiate them from Thai patients: they are older and more predominantly
male, while Thai patients are more likely to be younger and female. In essence, their
health concerns are quite similar to those of Thais; Health check-ups are very
common in both groups. However, medical tourists are more likely to be having
operations, with the result that their hospital stays are longer than those of Thai
patients.
1. Numbers
734,150 patients visited the five private hospitals in the study during 2010, making
3,096,628 separate visits (Table 4.7). Of these, Thai patients dominated, accounting
for 68% of patients and approximately 70% of visits. However, international patients
represented a sizeable minority: about 32% of the total number of patients. Among
international patients, medical tourists were the largest group, accounting for 44%,
followed by expatriates and sick tourists (Table 4.7). Thai patients tended to visit
hospital more frequently than medical tourists. The utilization rates of Thai patients
and medical tourists were 4.39 and 3.10 visits per patient, per year, respectively.
Table 4.13 shows that the number of visits per Thai patient is much more than that of
a medical tourist, accounting for a 7-fold difference. This means that domestic Thai
patients are still the main customers in these private hospitals, though the hospitals
present themselves as international hospitals for overseas patients.
103
Table 4.7: Number of patients and visits in the five hospitals in 2010, by types of patients
Thai private
patients
International patients Total
patients Medical
tourists
Expatriates Being ill
tourists
Number of patients Count 497,265 104,830 74,063 57,992 734,150
% 67.7 14.3 10.1 7.9 100.0
Number of visits Count 2,184,715 324,906 355,687 231,320 3,096,628
% 70.6 10.5 11.5 7.5 100.0
Utilization rate 4.39 3.10 4.80 3.99 4.22
2. Gender
The pattern of gender among medical tourists differed from that among Thai private
patients. Males predominated among medical tourists, whereas females
predominated among Thai patients (Table 4.8).
Table 4.8: Gender comparison between medical tourists and Thai private patients
Medical tourists Thai private patients
Count % Count %
Male 60,828 58.0 199,128 40.1
Female 43,982 42.0 297,829 59.9
Total 104,810 100.0 496,957 100.0
Statistical analysis
From table 4.8, Pearson’s Chi-square test is employed to prove whether there is any
difference in gender distribution between medical tourists and Thai private patients.
A statistically significant difference in gender distribution (p value < 0.0001) was
found between medical tourists and Thai private patients.
3. Age
Medical tourists tend to be older than Thai private patients. In the younger age group
(under 35), 46% were Thai, while only 33% were medical tourists (Table 4.9).
However, in the oldest age group (over 65), the proportions were equal,
104
approximately 9% of total patient number. The average age of a medical tourist was
41.7 year, while that of Thai patients was 37.2 year (Table 4.10). Male medical
tourists were older than female medical tourists. Their average ages were 43.1 year
and 39.7 year respectively (Table 4.10). In contrast, male Thai patients were slightly
younger than female – with an average of 36.2 year and 38 year respectively. In
general, medical tourists were older than Thai private patients.
Table 4.9: Age distribution between medical tourists and Thai private patients
Medical tourists Thai private patients
Count % Count %
Overall Less than 25 15,335 14.6 113,430 22.8
25-34 19,821 18.9 117,144 23.6
35-44 22,791 21.7 99,976 20.1
45-54 21,878 20.9 72,352 14.6
55-64 15,684 15.0 49,770 10.0
More than 65 9,283 8.9 44,284 8.9
Total 104,792 100.0 496,956 100.0
Male Less than 25 7,624 12.5 54,168 27.2
25-34 10,415 17.1 40,036 20.1
35-44 13,366 22.0 37,932 19.0
45-54 13,469 22.1 28,901 14.5
55-64 9,892 16.3 20,529 10.3
More than 65 6,050 9.9 17,562 8.8
Total 60,816 100.0 199,128 100.0
Female Less than 25 7,711 17.5 59,262 19.9
25-34 9,406 21.4 77,108 25.9
35-44 9,425 21.4 62,044 20.8
45-54 8,409 19.1 43,451 14.6
55-64 5,792 13.2 29,241 9.8
More than 65 3,233 7.4 26,722 9.0
Total 43,976 100.0 297,828 100.0
Table 4.10: Average age of medical tourists and Thai private patients
Type of patient Gender Mean N Std.
Deviation
Minimum Maximum Median
Medical tourists Male 43.15 60,816 17.01 0 101 44.00
Female 39.76 43,976 17.09 0 106 40.00
Total 41.73 104,792 17.12 0 106 42.00
Thai patients Male 36.18 199,128 20.33 0 117 36.00
Female 38.01 297,828 18.67 0 106 36.00
Total 37.28 496,956 19.37 0 117 36.00
105
Statistical analysis
A two independent sample T-test was employed to find out whether there is any
difference in the average age of medical tourists and Thai private patients. The null
hypothesis was that there was no difference in age between the two groups. A
statistically significant difference (p value < 0.0001) was found in the average age of
medical tourists and Thai private patients.
4. Disease pattern
4.1 Male comparison
Diseases in the male medical tourist were slightly different to those in male Thai
patients. Health check-ups, including medical counselling and treatment follow-up,
were the most common reason for visiting hospital in each group, accounting for
34% of visits by medical tourists and 22.6% of those by Thai patients (Table 4.11).
Digestive problems were the second commonest reason for male medical tourists to
visit, while respiratory problems prompted the visits of male Thai patients. Male
medical tourists tended to visit for neoplasm concerns, the treatment for these being
more elective and less urgent, while Thai males were admitted for more urgent
matters such as injuries and poisoning.
106
Table 4.11: Disease patterns among male medical tourists and male Thai private patients
Rank in
medical
tourist
Male diagnosis
(ICD-10 classification)
Medical tourists Thai private patients Rank
in
Thai
patient Count % Count %
1 Health examination, medical consultation and treatment
follow-up
54,946 33.9 146,675 22.6 1
2 Diseases of the digestive system 15,441 9.5 52,589 8.1 3
3 Diseases of the circulatory system 12,417 7.7 48,849 7.5 4
4 Diseases of the musculo-skeletal system and connective tissue 10,560 6.5 43,367 6.7 5
5 Endocrine, nutritional and metabolic diseases 9,754 6.0 32,814 5.1 6
6 Diseases of the genito-urinary system 9,507 5.9 20,131 3.1 12
7 Neoplasms 7,867 4.8 13,495 2.1 13
8 Diseases of the skin and subcutaneous tissue 7,447 4.6 31,139 4.8 9
9 Diseases of the eye and adnexa 6,486 4.0 22,601 3.5 10
10 Infectious and parasitic diseases 5,782 3.6 31,243 4.8 8
11 Diseases of the respiratory system 5,135 3.2 109,190 16.8 2
12 Diseases of the nervous system 4,228 2.6 11,536 1.8 15
13 Mental and behavioral disorders 3,883 2.4 12,544 1.9 14
14 Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified
3,575 2.2 20,166 3.1 11
15 Diseases of the ear and mastoid process 2,823 1.7 10,684 1.6 16
16 Diseases of the blood and blood-forming organs and the
immune mechanism
950 0.6 2,544 0.4 18
17 Congenital malformations, deformations and chromosomal
abnormalities
866 0.5 1,579 0.2 19
18 Injury, poisoning and certain other consequences of external
causes
322 0.2 32,046 4.9 7
19 Pregnancy, childbirth and the puerperium 142 0.1 412 0.1 21
20 Certain conditions originating in the perinatal period 88 0.1 1,134 0.2 20
21 External causes of morbidity and mortality 68 0.0 3,313 0.5 17
Statistical analysis
From table 4.11, Pearson’s Chi-square test was employed to find out whether there
was any difference in disease patterns between male medical tourists and male Thai
private patients. A statistically significant difference in disease pattern (p value <
0.0001) was found between male medical tourists and male Thai private patients.
4.2 Female comparisons
The disease pattern in females also differed between medical tourists and Thai
private patients. The most common reason for visits was health check-ups, including
107
medical counselling and treatment follow-up (Table 4.12). 41% of female medical
tourists visited hospitals for physical check-ups, compared to 26% of female Thais.
However, the second reason female medical tourists visited hospital was for diseases
of the genito-urinary system, while among female Thai patients these visits were
prompted by diseases of the respiratory system. Like males, female medical tourists
tended to visit for neoplasm problems and female Thai patients for problems
associated with injuries and poisoning.
Table 4.12: Disease patterns among female medical tourists and female Thai private patients
Rank in
medical
tourist
Female diagnosis
(ICD-10 classification)
Medical tourists Thai private patients Rank
in
Thai
patient Count % Count %
1 Health examination, medical consultation and treatment
follow-up
54,553 41.0 271,258 25.9 1
2 Diseases of the genito-urinary system 11,559 8.7 57,130 5.5 6
3 Diseases of the digestive system 9,079 6.8 78,596 7.5 3
4 Neoplasms 8,744 6.6 31,675 3.0 13
5 Diseases of the musculo-skeletal system and connective tissue 8,615 6.5 76,215 7.3 4
6 Endocrine, nutritional and metabolic diseases 7,835 5.9 48,450 4.6 8
7 Diseases of the skin and subcutaneous tissue 6,866 5.2 66,709 6.4 5
8 Diseases of the circulatory system 5,166 3.9 48,652 4.6 7
9 Diseases of the eye and adnexa 3,895 2.9 38,643 3.7 11
10 Infectious and parasitic diseases 3,361 2.5 41,836 4.0 9
11 Diseases of the respiratory system 2,695 2.0 136,971 13.1 2
12 Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified
2,385 1.8 35,173 3.4 12
13 Diseases of the nervous system 2,162 1.6 18,893 1.8 14
14 Diseases of the ear and mastoid process 1,526 1.1 16,219 1.5 15
15 Diseases of the blood and blood-forming organs and the
immune mechanism
1,395 1.0 6,158 0.6 17
16 Mental and behavioural disorders 1,073 0.8 15,848 1.5 15
17 Pregnancy, childbirth and the puerperium 1,029 0.8 9,171 0.9 16
18 Congenital malformations, deformations and chromosomal
abnormalities
904 0.7 2,498 0.2 19
19 Injury, poisoning and certain other consequences of external
causes
167 0.1 41,375 3.9 10
20 Certain conditions originating in the perinatal period 79 0.1 1,232 0.1 20
21 External causes of morbidity and mortality 71 0.1 5,193 0.5 18
108
Statistical analysis
From table 4.12, Pearson’s Chi-square test was employed to find out whether there
was any difference in disease patterns between female medical tourists and female
Thai private patients. A statistically significant difference in disease patterns (p value
< 0.0001) was found between female medical tourists and female Thai private
patients.
In Tables 4.11 and 4.12 it can be seen that health check-ups, including medical
consultations, are the most common reason for hospital visits among medical tourists
and Thai patients. This kind of service needs less advanced and comprehensive
medical equipment and does not usually need to be carried out by highly skilled
professionals – particularly sub-specialists. Nevertheless, disease patterns among
medical tourists and Thai patients were comparatively different.
5. Type of procedure
5.1 Male comparison
In 2010, 6,255 operations were performed in the five hospitals on male medical
tourists and 9,955 on male Thai patients, with an operation rate of 10.29 and 5.00
procedures per 100 patients, respectively (Table 4.13). The pattern of procedures
among male medical tourists and Thai patients was comparatively different. Heart-
related procedures, procedures on the digestive system and orthopaedic procedures
were the commonest among male medical tourists. Heart-related procedures
represented 42% of the total procedures in male medical tourists, but only 24% of
procedures in male Thai patients. The proportion of heart-related procedures is
relatively high, because one of the hospitals in this study specialises in this area of
treatment, and is well known for heart operations. Procedures on the digestive,
orthopaedic and heart-related systems were the commonest among Thai male
patients.
109
Table 4.13: Procedures in male medical tourists and male Thai private patients
Rank in
medical
tourist
Male procedure
(ICD-9 CM classification)
Medical tourists Thai private patients Rank in
Thai
patient Count % Count %
1 Miscellaneous and therapeutic procedures
(mostly cardiac catheter insertion) 1,057 16.9 1,224 12.3 3
2 Digestive system 919 14.7 1,955 19.6 1
3 Procedures and interventions, not classified
elsewhere (mostly angio-cardiogram) 728 11.6 521 5.2 7
4 Cardiovascular system 728 11.6 897 9.0 5
5 Musculo-skeleton system 617 9.9 1,488 14.9 2
6 Integumentary system (mostly cosmetic
surgery) 399 6.4 400 4.0 11
7 Eyes 375 6.0 928 9.3 4
8 Nose, mouth and pharynx 312 5.0 394 4.0 12
9 Male genitalia 282 4.5 440 4.4 9
10 Urinary system 267 4.3 427 4.3 10
11 Nervous system 203 3.2 547 5.5 6
12 Respiratory system 202 3.2 495 5.0 8
13 Haemic and lymphatic system 77 1.2 77 0.8 14
14 Ear 38 0.6 51 0.5 15
15 Endocrine system 34 0.5 101 1.0 13
16 Other diagnostic and therapeutic procedures 16 0.3 8 0.1 16
Total 6,255 100.0 9,955 100.0
Operation rate (procedures per 100 patients) 10.29 5.00
Statistical analysis
From table 4.13, Pearson’s Chi-square test was employed to find out whether there
was any difference in procedure patterns between male medical tourists and male
Thai private patients. A statistically significant difference in procedure pattern
(p value < 0.0001) was found between male medical tourists and male Thai private
patients.
5.2 Female comparison
In 2010, there were 6,153 procedures in female medical tourists and 16,782
procedures in female Thai patients (Table 4.14). The procedure patterns among
female medical tourists also differed from those in Thai patients. Cosmetic
operations, gynaecological procedures and procedures on the digestive system were
110
the most common among female medical tourists, while gynaecological and obstetric
procedures and procedures on the digestive system were more common among
female Thai patients. Almost one third of the total number of procedures among
female medical tourists was cosmetic-related, compared to only 9.4% among female
Thai patients. Meanwhile, gynaecological procedures were the commonest procedure
among female Thai patients.
Table 4.14: Procedures in female medical tourists and female Thai private patients
Rank in
medical
tourist
Female procedure
(ICD-9 CM classification)
Medical tourists Thai private patients Rank
in Thai
patient Count % Count %
1 Integumentary system (mostly cosmetic
surgery)
1,950 31.7 1,580 9.4 5
2 Gynaecological 846 13.7 2,822 16.8 1
3 Digestive system 665 10.8 2,201 13.1 2
4 Miscellaneous and therapeutic procedures
(mostly cardiac catheter insertion)
489 7.9 1,352 8.1 7
5 Eyes 416 6.8 1,429 8.5 6
6 Musculo-skeleton system 408 6.6 1,585 9.4 4
7 Cardiovascular system 272 4.4 685 4.1 9
8 Nose, mouth and pharynx 192 3.1 502 3.0 11
9 Procedures and interventions, not
elsewhere classified (mostly angio-
cardiogram)
167 2.7 203 1.2 14
10 Endocrine system 142 2.3 856 5.1 8
11 Obstetrics 139 2.3 1,998 11.9 3
12 Respiratory system 128 2.1 360 2.1 12
13 Nervous system 126 2.0 607 3.6 10
14 Urinary system 103 1.7 359 2.1 13
15 Haemic and lymphatic system 86 1.4 187 1.1 15
16 Ear 24 0.4 50 0.3 16
17 Other diagnosis and therapeutic
procedures
- 0.0 3 0.0 17
Total 6,153 100.0 16,782 100.0
Operation rate (procedures per 100 patients) 13.99 5.63
Statistical analysis
From table 4.14, Pearson’s Chi-square test was employed to find out whether there
was any difference in procedure patterns between female medical tourists and female
Thai private patients. A statistically significant difference in procedure pattern
111
(p value < 0.0001) was found between female medical tourists and female Thai
private patients.
Though a large percentage of medical tourists visited Thailand for health check-ups,
many visited for procedures. Heart-related procedures were most common among
men and cosmetic-related procedures among women. Operation rates among medical
tourists were higher than in Thai patients, in both men and women –2-fold and 2.5-
fold, respectively.
6. Length of stay
The overall length of stay among medical tourists differed slightly from that among
Thai private patients. The largest groups of medical tourists and Thai private patients
stayed in hospital for 3 days or less; 62.6% and 59.7%, respectively (Table 4.15).
The next largest groups in both categories stayed for up to a week. Among those who
stayed in hospital for more than 2 weeks, a higher percentage was medical tourists
than Thai patients, 8.7 and 5.2% respectively.
Regarding differences in disease patterns and types of procedure, medical tourists
needing hospitalization tended to have more complex symptoms and require more
specific procedures. The average length of stay among medical tourists was slightly
longer than that of Thai private patients. The average duration among medical
tourists was 6.6 days per patient, while among Thai private patients it was 5 days
(Table 4.16).
112
Table 4.15: Length of stay of medical tourists and Thai private patients
Medical tourists Thai private patients
Count % Count %
Overall 1-3 days 4,977 62.6 22,599 59.7
4-7 days 1,504 18.9 10,314 27.2
8-14 days 780 9.8 2,996 7.9
15-30 days 403 5.1 1,265 3.3
More than 30 days 290 3.6 689 1.8
Total 7,954 100.0 37,863 100.0
Male 1-3 days 2,303 56.8 9,121 58.5
4-7 days 795 19.6 4,057 26.0
8-14 days 498 12.3 1,404 9.0
15-30 days 269 6.6 645 4.1
More than 30 days 192 4.7 355 2.3
Total 4,057 100.0 15,582 100.0
Female 1-3 days 2,673 68.6 13,478 60.5
4-7 days 709 18.2 6,257 28.1
8-14 days 282 7.2 1,592 7.1
15-30 days 134 3.4 620 2.8
More than 30 days 98 2.5 334 1.5
Total 3,896 100.0 22,281 100.0
Table 4.16: Average length of stay of medical tourists and Thai private patients
Mean N Std.
Deviation
Minimum Maximum Median
Medical tourists Male 7.76 4,057 17.043 1 360 3.00
Female 5.39 3,896 14.012 1 352 2.00
Total 6.60 7,953 15.676 1 360 3.00
Thai patients Male 5.61 15,829 11.190 0 341 3.00
Female 4.70 22,666 8.493 0 225 3.00
Total 5.08 38,495 9.703 0 341 3.00
Statistical analysis
From Table 4.16, a two independent sample T-test was employed to find out whether
there was any difference in average length of stay between medical tourists and Thai
private patients. The null hypothesis was that there was no difference in length of
stay between the two groups. A statistically significant difference (p value < 0.0001)
was found between the average lengths of stay of medical tourists and Thai private
patients.
113
7. Type of payment
The way medical tourists and Thai private patients paid for their treatment differed
markedly. The vast majority of payments for medical expenditure in hospitals by
medical tourists were by self-pay, accounting for 91% (Table 4.17). Though self-pay
was also the most common payment method for Thai private patients, the proportion
was only 54%. It seems that Thai private patients had more varied ways of paying.
29% used corporate contracts to subsidize these expenditures, compared to only
6.6% of medical tourists; in this study, this refers specifically to employer-financed
schemes. Private insurance was another method used by Thai private patients for
their medical expenses. 19% of Thais paid for their treatment with private insurance,
compared to less than 2% of medical tourists.
Table 4.17: Types of payment of medical tourists and Thai private patients
Medical tourists Thai private patients
Count % Count %
Self-pay 268,524 91.5 1,168,194 53.8
Insurance 5,631 1.9 416,395 19.2
Corporate contract 19,273 6.6 586,296 27.0
Total 293,428 100.0 2,170,885 100.0
Statistical analysis
From table 4.17, Pearson’s Chi-square test was employed to find out whether there
was any difference in type of payment between medical tourists and Thai private
patients. A statistically significant difference in type of payment (p value < 0.0001)
was found between medical tourists and Thai private patients.
In summary, a majority of patients at the five private hospitals in the study are Thais.
Medical tourists have a key market share among international patients, and have a
different demographic profile to Thais. Service profiles also show somewhat
different disease patterns. Health check-ups are the most common service for
medical tourists, implying that the “medical” part of their trip may not be its major
element, and Thailand may not need too many extra resources to deliver this.
114
However, some medical tourists are visiting Thailand for operations such as heart-
related, orthopaedic and cosmetic procedures, which are considered comparatively
expensive for the confined/restricted resources available in Thailand.
4.4 Regional comparison of medical tourists
All medical tourists treated in the five hospitals were grouped by region of origin.
Seven regions: Europe, North America, Australia and Oceania, Southeast Asia, the
Middle East, and other countries in Asia and Africa were classified for the purpose of
analysis, in order to describe demographic and service characteristics.
Medical tourists from long haul regions including Europe, North America and
Australia tended to have similar characteristics, while those from Asian and African
countries tended to share different characteristics. Patients from the Middle East
were the largest group of medical tourists from all regions. Men predominated in all
regions except Southeast Asia. Patients from long-haul regions tended to be older
and stayed in hospital for a shorter time than those from within region.
1. Number
As previously mentioned, patients from the Middle East represented the largest
percentage of medical tourists in the five hospitals, while those from Australia and
Africa comprised the smallest group (Table 4.18). African patients visited hospital
most frequently while European patients visited the least.
Table 4.18: Number of patients and visits of medical tourists by region
Region Total
Europe North America
Australia Southeast Asia
Middle East
Other Asia
Africa
Patient Count 14,004 9,481 3,949 14,730 40,554 16,869 3,957 103,578
% 13.52% 9.15% 3.81% 14.22% 39.15% 16.29% 3.82% 100.00%
Visit Count 35,607 29,089 11,962 52,744 124,909 49,931 17,806 322,048
% 11.06% 9.03% 3.71% 16.38% 38.79% 15.50% 5.53% 100.00
Utilization rate 2.54 3.07 3.03 3.58 3.08 2.96 4.50 3.11
115
2. Gender
In terms of gender, men predominated from all regions except Southeast Asia (Table
4.19). Patients from Australia had only a slightly higher percentage of men than
women: 52% and 48% respectively. Southeast Asia was the only region that had
more female patients than male.
Table 4.19: Gender distribution of medical tourists by region
Region Total
Europe North
America
Australia
Southeast
Asia
Middle
East
Other
Asia
Africa
Male Count 9,282 6,112 2,045 6,234 24,450 9,711 2,319 60,153
% 66.3% 64.5% 51.8% 42.3% 60.3% 57.6% 58.6% 58.1%
Female Count 4,717 3,367 1,904 8,491 16,103 7,154 1,638 43,374
% 33.7% 35.5% 48.2% 57.7% 39.7% 42.4% 41.4% 41.9%
Total Count 13,999 9,479 3,949 14,725 40,553 16,865 3,957 103,527
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Statistical analysis
From table 4.19, Pearson’s Chi-square test was employed to find out whether there
was any difference in gender distribution among medical tourists from seven regions.
A statistically significant difference in gender distribution (p value < 0.0001) was
found.
3. Age
Table 4.20 demonstrates the age distribution of medical tourists from each region.
Unequal distribution was found in each age group. The largest groups from all
regions fell in the 25-44 and 45-64 age groups. The largest group of patients in the
45-64 age group came from long-haul regions, including North America, Australia
and Europe, while the largest group of patients in the younger age group came from
within-region and Africa. Medical tourists from long-haul regions, except Africa,
were older than those from within-region. The highest average age was 45.35 year
116
among patients from North America and the lowest was 39.2 year among patients
from the Middle East (Table 4.21).
Table 4.20: Age distribution of medical tourists by regions
Region Total
Europe North
America
Australia Southeast
Asia
Middle
East
Other
Asia
Africa
Less than 25 Count 1,450 1,013 427 1,921 7,381 2,507 456 15,158
% 10.4% 10.7% 10.8% 13.0% 18.2% 14.9% 11.5% 14.6%
25-34 Count 2,254 1,325 712 2,367 9,306 2,792 825 19,587
% 16.1% 14.0% 18.0% 16.1% 23.0% 16.6% 20.9% 18.9%
35-44 Count 2,866 1,720 865 3,450 8,501 4,108 986 22,505
% 20.5% 18.1% 21.9% 23.4% 21.0% 24.4% 24.9% 21.7%
45-54 Count 3,091 2,257 925 3,271 7,525 3,721 812 21,609
% 22.1% 23.8% 23.4% 22.2% 18.6% 22.1% 20.5% 20.9%
55-64 Count 2,604 2,177 741 2,275 4,733 2,404 564 15,503
% 18.6% 23.0% 18.8% 15.4% 11.7% 14.3% 14.3% 15.0%
More than 65 Count 1,734 989 279 1,446 3,099 1,334 313 9,198
% 12.4% 10.4% 7.1% 9.8% 7.6% 7.9% 7.9% 8.9%
Total Count 13,999 9,481 3,949 14,730 40,545 16,866 3,956 103,560
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Table 4.21: Average age of medical tourists by region
Region Mean N Std. Deviation Minimum Maximum Median
Europe 45.10 13,999 16.76 0 99 46.00
North America 45.35 9,481 17.02 0 95 48.00
Australia 43.59 3,949 14.93 0 88 44.00
Southeast Asia 43.02 14,730 16.93 0 95 43.00
Middle East 39.19 40,545 17.24 0 106 39.00
Other Asia 41.43 16,866 17.12 0 100 42.00
Africa 41.81 3,956 16.12 0 91 41.00
Statistical analysis
Analysis of variance (ANOVA) test was employed to find out whether there was any
difference in average age among medical tourists from the seven regions. The null
hypothesis was that the average age of medical tourists from all regions was the
same. A statistically significant difference (p value < 0.0001) was found in average
age among medical tourists from the seven regions. Statistical analysis also found
117
that the average age of medical tourists from Europe was very similar to that of those
from North America (p value > 0.99) and also of that of those from other Asian and
African countries (p value > .999)
4. Disease patterns
4.1 Male comparison
Health check-ups and diseases of the digestive and circulatory systems were
common reasons for the hospital visits of male medical tourists from all regions
(Table 4.22). Disease patterns tended to be similar among male medical tourists from
long-haul regions, and among those from within region, except for Southeast Asia.
Health check-ups, including medical consultations, were the most common
procedures for patients from all regions: 30%-40% of the total. Infectious diseases
and neoplasms were common among male patients from Southeast Asia, while
diseases of the genito-urinary system and neoplasms were common in those from
Africa.
118
Table 4.22: Disease patterns in male medical tourists by region
Male diagnosis Region
Europe North
America
Australia Southeast
Asia
Middle
East
Other
Asia
Africa
Health examination, medical
consultation and treatment follow-up
Count 7,508 6,832 2,001 5,970 21,492 7,450 2,965
% 35.5% 40.0% 40.9% 31.0% 33.6% 29.3% 32.5%
Diseases of the digestive system Count 2,716 1,873 706 1,488 5,579 2,224 758
% 12.8% 11.0% 14.4% 7.7% 8.7% 8.8% 8.3%
Diseases of the circulatory system Count 1,497 1,041 251 1,893 4,319 2,528 845
% 7.1% 6.1% 5.1% 9.8% 6.8% 10.0% 9.3%
Diseases of the musculo-skeletal
system and connective tissue
Count 1,248 1,107 259 672 4,878 1,723 605
% 5.9% 6.5% 5.3% 3.5% 7.6% 6.8% 6.6%
Endocrine, nutritional and metabolic
diseases
Count 719 651 170 1,347 4,187 2,045 590
% 3.4% 3.8% 3.5% 7.0% 6.5% 8.0% 6.5%
Diseases of the genito-urinary system Count 1,160 748 222 950 4,116 1,463 792
% 5.5% 4.4% 4.5% 4.9% 6.4% 5.8% 8.7%
Neoplasms Count 813 648 153 1,733 2,525 1,307 660
% 3.8% 3.8% 3.1% 9.0% 3.9% 5.1% 7.2%
Diseases of the skin and subcutaneous
tissue
Count 984 939 296 503 3,183 1,208 203
% 4.6% 5.5% 6.1% 2.6% 5.0% 4.8% 2.2%
Diseases of the eye and adnexa Count 952 689 216 623 2,566 978 414
% 4.5% 4.0% 4.4% 3.2% 4.0% 3.8% 4.5%
Infectious and parasitic diseases Count 911 605 161 1,896 1,101 803 262
% 4.3% 3.5% 3.3% 9.9% 1.7% 3.2% 2.9%
Diseases of the respiratory system Count 590 429 123 616 2,221 949 173
% 2.8% 2.5% 2.5% 3.2% 3.5% 3.7% 1.9%
Diseases of the nervous system Count 378 364 49 348 2,065 776 223
% 1.8% 2.1% 1.0% 1.8% 3.2% 3.1% 2.4%
Mental and behavioural disorders Count 507 422 71 301 1,801 607 159
% 2.4% 2.5% 1.5% 1.6% 2.8% 2.4% 1.7%
Symptoms, signs and abnormal clinical
and laboratory findings
Count 379 282 72 427 1,650 568 176
% 1.8% 1.7% 1.5% 2.2% 2.6% 2.2% 1.9%
Diseases of the ear and mastoid
process
Count 622 292 89 171 1,140 381 110
% 2.9% 1.7% 1.8% .9% 1.8% 1.5% 1.2%
Diseases of the blood and the immune
mechanism
Count 84 83 11 137 435 113 81
% .4% .5% .2% .7% .7% .4% .9%
Congenital malformations, and
chromosomal abnormalities
Count 36 32 24 100 440 138 91
% .2% .2% .5% .5% .7% .5% 1.0%
Injury, poisoning and certain other
consequences of external causes
Count 49 16 10 26 186 26 10
% .2% .1% .2% .1% .3% .1% .1%
Pregnancy, childbirth and the
puerperium
Count 6 4 0 8 36 84 4
% .0% .0% .0% .0% .1% .3% .0%
Certain conditions originating in the
perinatal period
Count 3 18 0 16 24 25 2
% .0% .1% .0% .1% .0% .1% .0%
External causes of morbidity and
mortality
Count 14 4 5 7 27 8 2
% .1% .0% .1% .0% .0% .0% .0%
Total Count 21,176 17,079 4,889 19,232 63,971 25,404 9,125
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
119
Statistical analysis
From table 4.22, Pearson’s Chi-square test was employed to find out whether there
was any difference in disease patterns among male medical tourists from the seven
regions. A statistically significant difference in disease pattern (p value < 0.0001)
was found.
4.2 Female comparison
Similarly to men, health check-ups (including medical consultation and cosmetic-
related problems) and diseases of the genito-urinary system were common reasons
for female medical tourists from all regions to seek treatment (Table 4.23). Female
patients from long-haul regions, except Africa, tended to show somewhat similar
disease patterns, while those from within region also tended to show similar patterns
to each other. Health check-ups, including medical consultations and cosmetic-
related issues, were the most common reason for female medical tourists from all
regions to seek treatment – ranging from 63.2% in patients from Australia, the
highest figure, to 35.7% in patients from other Asian countries, the lowest figure.
Diseases of the musculo-skeletal system, metabolic diseases and neoplasms were
common problems in female patients from within regions. Diseases of the skin or
subcutaneous tissue, and musculo-skeletal diseases, were common problems in those
from long-haul regions.
120
Table 4.23: Disease patterns in female medical tourists by region
Female diagnosis Region
Europe North
America
Australia Southeast
Asia
Middle
East
Other
Asia
Africa
Health examination, medical
consultation and treatment follow-up
Count 5,164 5,133 3,453 10,744 19,193 7,482 2,583
% 45.1% 51.1% 63.2% 39.1% 38.9% 35.7% 36.7%
Diseases of the genito-urinary system Count 864 670 249 2,750 3,967 2,211 793
% 7.5% 6.7% 4.6% 10.0% 8.0% 10.5% 11.3%
Diseases of the digestive system Count 1,181 839 477 1,429 3,329 1,236 529
% 10.3% 8.4% 8.7% 5.2% 6.8% 5.9% 7.5%
Neoplasms Count 428 412 88 2,747 2,856 1,491 678
% 3.7% 4.1% 1.6% 10.0% 5.8% 7.1% 9.6%
Diseases of the musculo-skeletal
system and connective tissue
Count 478 413 103 1,221 4,420 1,401 536
% 4.2% 4.1% 1.9% 4.4% 9.0% 6.7% 7.6%
Endocrine, nutritional and metabolic
diseases
Count 321 405 158 1,848 3,195 1,469 410
% 2.8% 4.0% 2.9% 6.7% 6.5% 7.0% 5.8%
Diseases of the skin and subcutaneous
tissue
Count 561 573 290 787 2,980 1,248 271
% 4.9% 5.7% 5.3% 2.9% 6.0% 6.0% 3.9%
Diseases of the circulatory system Count 432 234 83 1,303 1,906 888 278
% 3.8% 2.3% 1.5% 4.7% 3.9% 4.2% 4.0%
Diseases of the eye and adnexa Count 454 334 159 687 1,407 580 190
% 4.0% 3.3% 2.9% 2.5% 2.9% 2.8% 2.7%
Infectious and parasitic diseases Count 297 164 48 1,574 631 463 162
% 2.6% 1.6% .9% 5.7% 1.3% 2.2% 2.3%
Diseases of the respiratory system Count 281 186 85 433 1,081 480 131
% 2.5% 1.9% 1.6% 1.6% 2.2% 2.3% 1.9%
Symptoms, signs and abnormal clinical
and laboratory findings
Count 162 126 29 515 1,030 396 114
% 1.4% 1.3% .5% 1.9% 2.1% 1.9% 1.6%
Diseases of the nervous system Count 111 101 25 353 1,096 372 96
% 1.0% 1.0% .5% 1.3% 2.2% 1.8% 1.4%
Diseases of the ear and mastoid
process
Count 253 110 42 184 614 257 51
% 2.2% 1.1% .8% .7% 1.2% 1.2% .7%
Diseases of the blood and the immune
mechanism
Count 54 40 13 258 714 238 78
% .5% .4% .2% .9% 1.4% 1.1% 1.1%
Mental and behavioural disorders Count 155 96 38 232 260 232 34
% 1.4% 1.0% .7% .8% .5% 1.1% .5%
Pregnancy, childbirth and the
puerperium
Count 140 149 30 182 171 303 54
% 1.2% 1.5% .5% .7% .3% 1.4% .8%
Congenital malformations, and
chromosomal abnormalities
Count 67 43 55 167 374 162 32
% .6% .4% 1.0% .6% .8% .8% .5%
Injury, poisoning and certain other
consequences of external causes
Count 32 5 27 25 42 32 4
% .3% .0% .5% .1% .1% .2% .1%
Certain conditions originating in the
perinatal period
Count 8 4 0 29 13 20 5
% .1% .0% .0% .1% .0% .1% .1%
External causes of morbidity and
mortality
Count 14 4 15 13 14 8 3
% .1% .0% .3% .0% .0% .0% .0%
Total Count 11,457 10,041 5,467 27,481 49,293 20,969 7,032
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
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Statistical analysis
From table 4.23, Pearson’s Chi-square test was employed to find out whether there
was any difference in disease patterns among female medical tourists from the seven
regions. A statistically significant difference in disease pattern (p value < 0.0001)
was found.
5. Procedures
In 2010, 12,400 procedures were performed on medical tourists in the five private
hospitals (Table 4.24); 6,253 on male and 6,147 on female patients. In terms of
gender, among patients from Europe, the Middle East, Africa and other Asian
countries, higher numbers of procedures were carried on male than on female
patients. By contrast, among patients from Australia, the number of procedures
carried out on female patients was substantially higher than that of procedures on
males: 81%.
Table 4.24: Number of procedures among medical tourists in the five private hospitals, in 2010, by region
Male % within
region
Female % within
region
Total %
between
regions
Europe 842 57.4 625 42.6 1,467 11.83
North America 597 49.1 620 50.9 1,217 9.81
Australia and Oceania 262 18.6 1,150 81.4 1,412 11.39
Southeast Asia 988 47.1 1,110 52.9 2,098 16.92
Middle East 2,163 58.1 1,561 41.9 3,724 30.03
Other parts of Asia 891 54.4 746 45.6 1,637 13.20
Africa 510 60.4 335 39.6 845 6.81
Total 6,253 50.4 6,147 49.6 12,400 100.00
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5.1 Male comparison
Patterns of procedures among male patients from long-haul regions were
comparatively similar, while patterns among in those from within regions and Africa
were also comparatively similar (Table 4.25). Heart-related procedures and
procedures on the digestive system were two of the most common procedures among
male patients from within-region and Africa. Heart-related procedures, including
cardiac catheterization, coronary angiograms and other cardiac operations were the
largest category of procedure among patients from these regions, accounting for
almost half of all procedures. Cosmetic, heart-related, orthopaedic and digestive
procedures were common operations in male patients from long-haul regions.
Orthopaedic procedures were the most common in those from North America,
cosmetic procedures were most frequent in those from Australia, and digestive
operations were most frequent in those from Europe.
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Table 4.25: Type of procedure in male medical tourists by regions
Male procedure Region
Europe North
America
Australia Southeast
Asia
Middle
East
Other
Asia
Africa
Miscellaneous and therapeutic
procedures (mostly cardiac
catheter insertion)
Count 100 72 25 203 362 198 97
% 11.9% 12.1% 9.5% 20.5% 16.7% 22.2% 19.0%
Digestive system Count 151 61 31 152 290 159 75
% 17.9% 10.2% 11.8% 15.4% 13.4% 17.8% 14.7%
Procedures and interventions, not
elsewhere classified (mostly
angio-cardiogram)
Count 58 19 8 144 330 130 39
% 6.9% 3.2% 3.1% 14.6% 15.3% 14.6% 7.6%
Cardiovascular system Count 69 34 8 165 258 106 88
% 8.2% 5.7% 3.1% 16.7% 11.9% 11.9% 17.3%
Musculo-skeleton system Count 118 140 28 50 173 69 39
% 14.0% 23.5% 10.7% 5.1% 8.0% 7.7% 7.6%
Integumentary system (mostly
cosmetic surgery)
Count 76 107 69 17 111 11 8
% 9.0% 17.9% 26.3% 1.7% 5.1% 1.2% 1.6%
Eyes Count 105 54 37 29 89 28 33
% 12.5% 9.0% 14.1% 2.9% 4.1% 3.1% 6.5%
Nose, mouth and pharynx Count 28 26 28 45 151 28 6
% 3.3% 4.4% 10.7% 4.6% 7.0% 3.1% 1.2%
Male genitalia Count 35 41 13 22 106 34 31
% 4.2% 6.9% 5.0% 2.2% 4.9% 3.8% 6.1%
Urinary system Count 36 9 3 47 110 31 31
% 4.3% 1.5% 1.1% 4.8% 5.1% 3.5% 6.1%
Respiratory system Count 21 8 5 42 54 53 19
% 2.5% 1.3% 1.9% 4.3% 2.5% 5.9% 3.7%
Nervous system Count 29 13 3 40 69 22 25
% 3.4% 2.2% 1.1% 4.0% 3.2% 2.5% 4.9%
Haemic and lymphatic system Count 6 4 0 15 33 10 9
% .7% .7% .0% 1.5% 1.5% 1.1% 1.8%
Ear Count 1 0 3 8 16 7 3
% .1% .0% 1.1% .8% .7% .8% .6%
Endocrine system Count 5 2 0 7 10 5 5
% .6% .3% .0% .7% .5% .6% 1.0%
Other diagnostic and therapeutic
procedures
Count 4 7 1 1 1 0 2
% .5% 1.2% .4% .1% .0% .0% .4%
Total Count 842 597 262 988 2,163 891 510
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
124
Statistical analysis
From table 4.25, Pearson’s Chi-square test was employed to find out whether there
was any difference in patterns of procedure among male medical tourists from the
seven regions. A statistically significant difference in procedure pattern (p value <
0.0001) was found.
5.2 Female comparison
Similar to picture among male medical tourists, patterns of procedure in female
patients from long-haul regions were comparatively similar, while patterns among
those from within-region and Africa were also comparatively similar (Table 4.26).
Cosmetic-related procedures, including skin and eye operations, were dominated by
female patients from long-haul regions, particularly those from Australia –
approximately 90% of total procedures. Gynaecological, digestive, heart-related and
cosmetic procedures were common among patients from within-region and Africa.
In conclusion, types of procedures among medical tourists can be classified into two
groups: those from Europe, North America and Australia and those from Asian
countries and Africa. Heart-related procedures dominate in male patients from Asia
and Africa, while cosmetic-related procedures dominate in female patients from
long-haul regions.
125
Table 4.26: Type of procedure in female medical tourists by region
Female procedure Region
Europe North
America
Australia Southeast
Asia
Middle
East
Other
Asia
Africa
Integumentary system (mostly
cosmetic surgery)
Count 266 290 902 203 162 88 34
% 42.6% 46.8% 78.4% 18.3% 10.4% 11.8% 10.1%
Gynaecological Count 77 76 24 193 280 129 67
% 12.3% 12.3% 2.1% 17.4% 17.9% 17.3% 20.0%
Digestive system Count 24 36 12 173 268 101 51
% 3.8% 5.8% 1.0% 15.6% 17.2% 13.5% 15.2%
Miscellaneous and therapeutic
procedures (mostly cardiac
catheter insertion)
Count 28 17 13 130 170 93 38
% 4.5% 2.7% 1.1% 11.7% 10.9% 12.5% 11.3%
Eyes Count 85 81 132 37 47 11 23
% 13.6% 13.1% 11.5% 3.3% 3.0% 1.5% 6.9%
Musculo-skeleton system Count 31 32 11 75 166 67 26
% 5.0% 5.2% 1.0% 6.8% 10.6% 9.0% 7.8%
Cardiovascular system Count 15 1 5 82 102 43 24
% 2.4% .2% .4% 7.4% 6.5% 5.8% 7.2%
Nose, mouth and pharynx Count 28 16 28 26 50 31 12
% 4.5% 2.6% 2.4% 2.3% 3.2% 4.2% 3.6%
Procedures and interventions, not
classified elsewhere (mostly
angio-cardiogram)
Count 14 3 6 26 76 28 14
% 2.2% .5% .5% 2.3% 4.9% 3.8% 4.2%
Endocrine system Count 17 23 10 24 30 32 6
% 2.7% 3.7% .9% 2.2% 1.9% 4.3% 1.8%
Obstetrics Count 10 25 1 45 7 37 14
% 1.6% 4.0% .1% 4.1% .4% 5.0% 4.2%
Respiratory system Count 14 7 5 35 47 15 5
% 2.2% 1.1% .4% 3.2% 3.0% 2.0% 1.5%
Nervous system Count 4 4 1 17 64 26 10
% .6% .6% .1% 1.5% 4.1% 3.5% 3.0%
Urinary system Count 8 4 0 28 39 16 8
% 1.3% .6% .0% 2.5% 2.5% 2.1% 2.4%
Haemic and lymphatic system Count 4 3 0 13 41 23 2
% .6% .5% .0% 1.2% 2.6% 3.1% .6%
Ear Count 0 2 0 3 12 6 1
% .0% .3% .0% .3% .8% .8% .3%
Total Count 625 620 1,150 1,110 1,561 746 335
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Statistical analysis
From table 4.26, Pearson’s Chi-square test was employed to find out whether there
was any difference in patterns of procedure among female medical tourists from the
126
seven regions. A statistically significant difference in procedure pattern (p value <
0.0001) was found.
6. Length of stay
Medical tourists from each region differed slightly in the pattern of length of stay.
The largest group, from all regions, stayed in hospital for 3 days or less (Table 4.27).
Patients from the Middle East and Africa were more likely to stay for longer than 30
days, compared to those from other regions. Australian medical tourists made the
shortest stays, approximately 2.32 days per patient, while those from the Middle East
stayed the longest, approximately 10.53 days per patient (Table 4.28).
Table 4.27: Length of stay of medical tourists by region
Region
Europe North America
Australia Southeast Asia
Middle East
Other Asia
Africa
1-3 days Count 631 577 781 811 1,264 649 255
% 59.2% 74.5% 87.8% 57.0% 57.2% 59.0% 53.1% 4-7 days Count 229 128 77 318 408 236 108
% 21.5% 16.5% 8.7% 22.3% 18.5% 21.5% 22.5% 8-14 days Count 122 38 16 178 230 130 66
% 11.4% 4.9% 1.8% 12.5% 10.4% 11.8% 13.8% 15-30 days Count 60 20 15 86 122 65 35
% 5.6% 2.6% 1.7% 6.0% 5.5% 5.9% 7.3% More than 30 days Count 24 12 1 30 187 20 16
% 2.3% 1.5% .1% 2.1% 8.5% 1.8% 3.3%
Total Count 1,066 775 890 1,423 2,211 1,100 480
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Table 4.28: Average length of stay of medical tourists by region
Region New 2 Mean N Std.
Deviation
Minimum Maximum Median
Europe 5.36 1,066 7.56 1 87 3.00
North America 3.75 775 7.17 1 111 2.00
Australia 2.32 890 2.90 1 32 2.00
Southeast Asia 5.87 1,423 9.61 1 138 3.00
Middle East 10.53 2,211 24.54 1 360 3.00
Other Asia 5.49 1,100 8.13 1 87 3.00
Africa 8.55 480 22.80 1 352 3.00
Total 6.60 7,945 15.68 1 360 3.00
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Statistical analysis
From table 4.28, an analysis of variance (ANOVA) test was employed to find out
whether there was any difference in the average length of stay among medical
tourists from the seven regions. The null hypothesis was that the average length of
stay of medical tourists from all regions was the same. A statistically significant
difference (p value < 0.0001) was found: therefore the average length of stay of
medical tourists from the seven regions was not the same. Statistical analysis also
found that the average length of stay among medical tourists from Europe was very
similar to that of patients from other Asian countries (p value > 0.999) and those
from Southeast Asia (p value > .95)
7. Type of payment
Type of payment used by medical tourists from all regions was reasonably similar.
Most of them used self-pay (4.29). Private insurance and corporate contract were
alternative sources of payment, but they were used infrequently.
Table 4.29: Type of payment by medical tourist by region
Region
Europe North
America
Australia Southeast
Asia
Middle
East
Other
Asia
Africa
Self-pay Count 28,683 22,757 8,329 43,618 108,386 40,585 13,856
% 89.4% 85.7% 86.7% 91.8% 95.0% 89.5% 89.2%
Insurance Count 1,584 1,614 296 423 151 1,414 84
% 4.9% 6.1% 3.1% .9% .1% 3.1% .5%
Corporate contract Count 1,828 2,193 981 3,459 5,545 3,366 1,597
% 5.7% 8.3% 10.2% 7.3% 4.9% 7.4% 10.3%
Total Count 32,095 26,564 9,606 47,500 114,082 45,365 15,537
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Statistical analysis
From table 4.29, Pearson’s Chi-square test was employed to find out whether there
was any difference in type of payment among medical tourists from the seven
128
regions. A statistically significant difference in type of payment (p value < 0.0001)
was found.
It is apparent that medical tourists from western regions tend to have similar medical
problems to those from Asia, including those from Africa. Long-haul patients usually
come with digestive and circulatory problems, while Asian patients come with a
variety of diseases. Asian patients usually visit hospitals for heart procedures while
Western patients are more likely to receive cosmetic procedures. A difference in
disease patterns in the two regions, and the ways in which hospitals promote their
services to each country contribute to these differences.
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4.5 Discussion and conclusion
This section presents a summary of research findings, general discussion on findings
concerning various aspects of the characteristics of medical tourists, a discussion on
data limitations in the analysis, and the conclusion.
o Summary of research findings
Medical tourists have significantly different characteristics from non-medical tourists
from many aspects. They travel mostly from the Middle East, Southeast Asia,
Europe and South Asia, accounting for 66% of the total number of medical tourists,
while Southeast Asia, Europe and East Asia are the key markets for non-medical
tourists, accounting for 80% of the total. Patients from the Middle East represent the
largest market share among medical tourists: almost 40%. In terms of gender, men
predominate among both medical and non-medical tourists. Because of the nature of
their diseases, medical tourists tend to be older than non-medical tourists.
Thai patients predominate in the five private hospitals in this study, accounting for
68% of total patient numbers, while only 32% are international patients. Of all
international patients, 44% are medical tourists; this is considered to be the largest
group, the others being expatriates and sick tourists. Medical tourists have some
characteristics that differentiate them from Thai private patients. They are older and
predominantly male, while Thais tend to be younger and predominantly female.
Their disease patterns are also quite different to those of Thais. Health check-ups are
the most common reason for hospital visits, around 34% in men and 41% in women,
followed by digestive, circulatory and musculo-skeletal problems. It is apparent that
they visit Thailand for operations, heart-related, orthopaedic and cosmetic
procedures being the most common. They stay in hospitals for longer periods than
Thais, approximately 6.60 and 5.08 days per patient, respectively. Most medical
tourists, around 90%, use out-of-pocket payment for their medical expenses.
Medical tourists are not a homogeneous group; their characteristics differ between
regions. Those from long haul regions including Europe, North America and
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Australia tend to have similar characteristics, while those from Asian countries and
Africa tend to share characteristics. Patients from the Middle East are the largest
group (40%) while those from Australia are the smallest (3.8%). Men predominate
in all regions except Southeast Asia. Patients from long-haul regions tend to be older
and stay in hospitals for a shorter time than those from within-region. Patients from
long-haul regions usually visit hospitals with digestive and circulatory problems,
while those from Asia and Africa come with a larger variety of problems. Cosmetic
operations, followed by heart-related operations are the most popular for long-haul
patients. Heart-related operations followed by digestive operations are the most
popular among Asian and African patients.
In conclusion, this study clearly shows the characteristics of medical and non-
medical tourists. The typical medical tourist in Thailand can be categorised into three
groups. The first and largest group is a middle-aged male patient from the Middle
East seeking heart procedures. The second group is a middle-aged female patient
from Southeast Asia traveling for cosmetic or gynaecological procedures. The last
would be a middle-aged European male patient travelling for digestive and
orthopaedic procedures. In contrast, typical non-medical tourists are younger men
from Southeast Asia, East Asia and Europe.
o General discussion
As discussed in Chapter Three, there is a shortage of evidence concerning medical
tourists in terms of their demography and service behaviours. This information,
being mostly in the private sector, has been difficult to access due to business
confidentiality. Because of the lack of detail given and the comparatively low
response from private hospitals, the only existing data sources are the Survey of the
Department of Foreign Export, Ministry of Commerce (MOC) and the 5-yearly
private hospital survey carried out by the Thai National Statistical Office. However,
both data sources usually have only aggregated numbers of patients and have
difficulty in differentiating medical tourists from other international patients. Hence,
this study has tried to establish empirical evidence concerning medical tourists
within their demographic and service profiles.
131
The research findings show that there were 104,830 medical tourists making 324,906
separate visits, to the top-five private hospitals well-recognized for serving
international patients. This actual number of medical tourists extends our previous
existing knowledge of their numbers obtained from government trade and health
policy makers. For a long period Thai society has recognised that 1.5-2 million
foreign patients visit Thailand each year. This substantial number has made Thailand
the foremost provider of medical tourism in the region. This perceived number has
also led to many arguments from health and trade spokespeople about the possible
impact on the country.
It could be argued that this study examined only five private hospitals, while there
are more than 50 such hospitals in Thailand serving international patients. However,
these five hospitals were selected as the top five, based on data from the Ministry of
Commerce in 2007, having 65% of the market share of all international patients in
that year. This study also shows that two of the five treat a large proportion of all
medical tourists, accounting for 57% and 49% of the total number of international
patients in each hospital, while the other three treat comparatively smaller numbers,
accounting for 30%, 15% and 13% of their total numbers of international patients. In
addition, 90% of the medical tourists covered by this study were treated at these two
hospitals. This implies that, actually, there are very few hospitals engaging with the
medical tourist industry in Thailand, serving instead, in the main, the expatriate
community.
Currently, there is a clear understanding of the number of international patients, as
reported in the MOC survey. The actual number of patients is smaller than the 1.5-2
million per year quoted, as hospitals report their data in terms of the number of
separate visits, not in terms of patient numbers. Based on figures from this study,
medical tourists account for approximately 35% of the total visits of international
patients, and they make an average of 3.1 visits per year; so the estimated numbers
of medical tourists visiting Thailand annually should be between 172,000 to
223,000. .From this it can be seen that medical tourists represent a small minority of
132
total patient numbers in Thailand, and are perhaps not the cause for concern – or
celebration – that they have been.
This study also shows that the number of medical tourists small when compared to
ordinary international tourists and Thai patients. The number of medical tourists was
one fifth of the number of Thai patients in the five hospitals in 2010. They
represented only 14% of the total number, compared to 68% of Thai patients and
18% of other international patients. Numbers of medical tourists were marginal
compared to numbers of international tourists, accounting for only 0.6% of the total.
Furthermore, this figure is similar to the findings from the MOTS survey on “the
main purpose of visit”. Data from this survey indicated that only 0.5% of
international tourists cited medical treatment as the main purpose of their visit to
Thailand.
Analysis of the characteristics and behaviours of medical tourists and non-medical
tourists shows differences from all aspects. The reasons may be connected with the
issue mentioned above – i.e., that medical tourists are a very small group within the
larger population of ordinary international tourists. However, some interesting points
are raised by the analysis of regional distribution between medical tourists and
international tourists. It shows that tourists from the Middle East, Southeast Asia and
Europe include the highest numbers of medical tourists, while tourists from
Southeast Asia, Europe and East Asia are key sources of all international tourists.
Southeast Asia and Europe are already represented in both industries, while East
Asia and Middle East are not, but some people from these two regions are still in
Thailand as either ordinary or medical tourists. Thus, it would be possible that the
tourism industry could increase its activities in the Middle East to increase the
volume of business. The medical tourism industry could market itself in East Asia to
increase participation in the health element of tourism.
The analysis of disease patterns among medical tourists shows that approximately
34% of male and 41% of female medical tourists visited hospitals for health check-
ups. This information challenges the existing belief in Thailand that medical tourists
come there for advanced and sophisticated care, such as cardiac and orthopaedic
133
treatment, and that they compete with domestic patients in access to these health
services. Health check-ups need less sophisticated medical equipment and fewer
highly-skilled health personnel to operate it. This finding can perhaps lessen Thai
concerns on the negative impact medical tourists have on domestic private patients.
Findings from the analysis of the patterns of procedures shows that although the total
number of procedures among medical tourists is less than among Thai private
patients, the ratio is per patient is double, accounting for 11.84 and 5.38 procedures
per 100 patients. This implies that medical tourists visiting Thailand for some
procedures, particularly cosmetic, intend to get the maximum benefit from their
travel costs. The study shows that Australian female represent a majority of those
undergoing cosmetic procedures. This finding is supported by most Australian media
content concerning medical tourism; additionally, there is considerable promotion of
cosmetic surgery in low- and middle-income countries particularly [139]. It is also
noted that the only procedure carried out on more medical tourists than on Thai
private patients is cardiac catheterization; however, even in this case, it is difficult to
assert that medical tourists divert resources from local patients, as most Thais are
treated in public hospitals and the level of resources needed for cardiac
catheterization is much less than in open-chest surgery.
Analysis of procedures between source regions shows that long-haul patients tend to
seek cosmetic and heart-related procedures, which are comparatively expensive and
are not covered by national health insurance schemes in their countries. Meanwhile,
patients from Asian and African regions, considered to have somewhat less
developed healthcare facilities than Western countries, tend to visit Thai hospitals for
heart-related, digestive and orthopaedic procedures due to lack of provision in their
own countries. This knowledge enables Thailand to market itself to specific regions
as a medical tourism destination.
Analysis on the length of stay of medical tourists reveals that 3.6% stayed in
hospitals for more than 30 days, the largest proportion of this group being from the
Middle East. 30 days is the maximum period foreign tourists are allowed to stay in
Thailand. This regulation has been regarded as a barrier to the growth of medical
134
tourism, and the government is currently considering extending it, specifically for
patients from the Middle East. However, the findings of this study suggest the
current limit may not be as significant a barrier as current media and policy discourse
suggests.
o Conclusion
This is the first empirical in-depth study of the characteristics of medical tourists
visiting Thailand. It has identified the ways in which they differ demographically
from non-medical tourists, particularly in their regions of origin. This difference
allows trade sectors to market tourism and health activities to tourists who would not
necessarily have come to Thailand principally for these activities. This would be a
positive addition to the national economy. The ways in which medical tourists differ
from Thai private patients have also been identified. The study found that they come
for certain procedures in particular, such as heart-related, cosmetic, orthopaedic and
digestive operations, which would affect domestic patients particularly, as the fields
of heart and orthopaedic treatment have limited resources in Thailand. In order to
support the medical tourism industry and mitigate its implications for the domestic
health system, health sectors need an effective plan to produce more health
professionals. However, this chapter focuses specifically on the characteristics of
medical tourists; an understanding of their impact on the economy of Thailand is
described in the next chapter.
135
Chapter Five
Assessing the expenditure of medical tourism
on medical care and tourism revenues
136
Chapter 5 Assessing the expenditure of medical tourism on medical care
and tourism revenues
As demonstrated in the conceptual framework, medical tourists spent money on
medical goods and services such as physicians, medical staff, medications and
medical devices. However, in terms of the tourism element of their spending, it has
been well documented that this expenditure has a substantial economic impact on
destination economies [140], directly impacting on primary tourism sectors such as
accommodation, restaurants, entertainment and retail shops; other sectors are also
impacted, but less directly [141]. Bumrungrad International Hospital is a good
example of the considerable contribution of international patients to hospital
revenue; in 2009 the income from international customers contributed around 55%
of total revenue [142].
In terms of the literature, the study by Lautier (2008) of international patients in
Tunisia used face-to-face interviews with key informants in private and government
organizations to estimate the average length of stay and average spending. Johnson
and Garman (2010) estimated import and export revenues of medical travel in the
US, using well-systematized secondary data from a variety of organizations,
including telephone interviews with domestic healthcare organizers.
In Thailand, NaRanong et al (2011) estimated the economic impact of international
patients by using secondary data from the DEP survey, with additional assumptions.
This study estimates a medical service revenue of around 46,000-52,000 million
THB and a tourism revenue of around 12,000-13,000 million THB. Many other
organizations have tried to estimate medical tourism revenues. The Ministry of
Public Health estimated that the revenue from international patients in 2007 was
around 32,900 million THB, while Kasikorn Research Centre and the Ministry of
Commerce estimated these revenues at around 36,000 and 41,000 million THB
respectively [143]. However, there is ambiguity in the detail of their estimation
concerning whether a tourism spending component was included, and whether
137
spending by patients’ companions was taken into account. Furthermore, all
information based on secondary data is from diverse sources giving less detail in
their spending profiles.
Concerning the tourism industry in Thailand, systematic data collection on
international tourists has been established. An annual survey of international tourists
is conducted by the Ministry of Tourism and Sports (MOTS). Many detailed
questions about tourist profiles, their activities and spending patterns are included in
the questionnaire. Sampling of international tourists is via interviews at airports
when leaving the country.
In order to understand the economic contributions of medical tourism, this chapter
focuses on analysing the medical and tourism elements of the spending profiles of
medical tourists, compared with international tourist expenditures reported by
MOTS. It is crucial to determine the expenditure which would have occurred had
medical care not been part of the visit, and to identify the specific revenue
contribution of medical tourism to overall tourist revenue that would otherwise not
have occurred.
138
5.1 Aim and specific research questions
The aim of this chapter is to assess the expenditure of medical tourists on medical
care and tourism. A comparison with non-medical tourists and medical tourists’
companions is also made to illustrate how much they differ from each other. An
understanding of how much medical tourists and their companions spend on tourism
elements allows estimation of their actual additional economic impact separately
from their medical spending. These findings will help policy makers establish
strategies for enhancing the benefit to the country. To do this, several specific
research questions are addressed:
1. Does the tourism spending profile of medical tourists differ from that of non-
medical tourists?
2. Does the tourism spending profile of medical tourists’ companions differ from
that of non-medical tourists?
3. What are the factors influencing the tourism expenditure of medical and non-
medical tourists?
4. Does the medical spending of medical tourists differ from that of domestic Thai
private patients?
5. Does the medical spending of medical tourists differ by region of origin?
139
Results
5.2 Tourism behaviours of medical tourists
1. Demographic profiles
1.1 Region of origin
293 medical tourists from six regions participated in the survey. 200 patients were
from within the region, accounting for 68% of the total number, whereas 93 patients
were from long-haul regions (Table 5.1). In terms of region, the largest group of
participants was from the Middle East, whereas the smallest groups were those from
Europe and North America. In addition, all six regions were categorized into two
groups based on the location. Within-regions referred to all regions in Asia including
Southeast, South and East Asia and the Middle East, while long-haul regions
comprise Europe, North America, Australia and Oceania.
Table 5.1: Region and country of origin of participants
Region group Region Country Number of
participants
%
Long-haul regions
(93, 31.7%)
Europe (18, 6.1%) United Kingdom 7 2.4
France 6 2.0
Germany 5 1.7
North America (18, 6.1%) USA 16 5.5
Canada 2 0.7
Australia and Oceania (57, 19.5%) Australia 57 19.5
Within regions
(200, 68.3%)
Southeast Asia (19, 6.5%) Myanmar 16 5.5
Cambodia 3 1.0
Middle East (125, 42.7%) U.A.E. 51 17.4
Oman 36 12.3
Qatar 15 5.1
Kuwait 23 7.8
Other parts of Asia (56, 19.1%) Bangladesh 53 18.1
Japan 3 1.0
Total participants 293 100.0
140
1.2 Gender and age
Men predominated overall, approximately 58% of the total (Table 5.2), and also in
the within-region category; however, women predominated in the long-haul region
category. Gender distribution of participants is comparatively different from that of
medical tourists in the previous section, where men predominated in all regional
categories. This is because many Australian patients participated in this survey, the
majority of whom were females, usually visiting for cosmetic treatments. Most
participants were in the 35-54 age-group, which accounted for 46% (Table 5.3).
Participants from within-region were older than those from long-haul regions; the
average ages being 46 and 36 years old respectively (Table 5.4).
Table 5.2: Gender of participants by region
Long-haul regions Within region Total
Count % Count % Count %
Male 18 19.4 151 75.5 169 57.7
Female 75 80.6 49 24.5 124 42.3
Total 93 100.0 200 100.0 293 100.0
Table 5.3: Age group of participants by region
Long-haul regions Within region Total
Count % Count % Count %
Less than 25 yrs 17 18.3 12 6.0 29 9.9
25-34 yrs 34 36.6 25 12.5 59 20.1
35-44 yrs 19 20.4 53 26.5 72 24.6
45-54 yrs 12 12.9 53 26.5 65 22.2
55-64 yrs 9 9.7 39 19.5 48 16.4
More than 65 yrs 2 2.2 18 9.0 20 6.8
Total 93 100.0 200 100.0 293 100.0
Table 5.4: Average age of participants by region
Region Mean N Std.
Deviation
Minimum Maximum Median
Long-haul 36.08 93 13.043 19.00 79.00 32.00
Within region 46.28 200 13.336 15.00 83.00 46.00
Total 43.04 293 14.051 15.00 83.00 42.00
141
1.3 Occupation and income
The majority of participants were agricultural workers, administrative/managerial
employees, retired/unemployed and other occupations, accounting for 66% of total
participants (Table 5.5). Agricultural workers, administrative/managerial employees
and professionals were the main occupations of participants from long-haul regions.
Agricultural workers, administrative/managerial employees and retired/unemployed
were the main occupations of those from within region. With respect to their
occupations, approximately 40% of participants earned a comparatively low annual
income of less than 20,000 USD; only 5% earned more than 80,000 USD (Table
5.6).
Table 5.5: Occupation of participants by region
Long-haul regions Within region Total
Count % Count % Count %
Professionals 15 16.1 15 7.6 15 5.2
Administrative and Managerial 17 18.3 34 17.2 51 17.5
Government and Military 11 11.8 9 4.5 20 6.9
Clerical, salesman and
commercial 1 1.1 28 14.1 29 10.0
Housewife and unpaid family
workers 1 1.1 0 0.0 1 0.3
Student or child 0 0.0 2 1.0 2 0.7
Labourer 3 3.2 13 6.6 16 5.5
Agricultural worker 23 24.7 31 15.7 54 18.6
Retired and unemployed 6 6.5 33 16.7 39 13.4
Other 19 20.4 33 16.7 49 16.8
Total 93 100.0 198 100.0 291 100.0
Table 5.6: Income of participants by region
Long-haul regions Within region Total
Count % Count % Count %
Less than 20,000 USD 23 32.4 71 39.9 94 37.8
20,000-39,999 USD 31 43.7 53 29.8 84 33.7
40,000-59,000 USD 10 14.1 30 16.9 40 16.1
60,000-79,999 USD 5 7.0 14 7.9 19 7.6
More than 80,000 USD 2 2.8 10 5.6 12 4.8
Total 71 100.0 178 100.0 249 100.0
142
2. Tourism behaviour
2.1 Medical purpose of the visit
Approximately 34% of participants intended to visit Thailand exclusively for
medical purposes (Table 5.7). Almost half had medical treatment as their main
purpose together with other purposes. This means they had another reason for
travelling but it was less important than obtaining medical care. Only 16% decided to
visit Thailand and added medical services to their trip later. Participants from within
region tended to visit Thailand for the specific purpose of seeking medical care,
compared to those from long-haul regions: 45% and 16% respectively. Data from
this survey illustrates that most participants intended to receive medical services in
Thailand, even though they may have had other reasons for their trip as well.
Table 5.7: Level of importance of medical service for visit
Long-haul regions Within region Total
Count % Count % Count %
Main purpose 48 60.0 54 40.6 102 47.9
Only one purpose 13 16.3 59 44.4 72 33.8
Included later 19 23.8 20 15.0 39 18.3
Total 80 100.0 133 100.0 213 100.0
2.2 Revisit for medical treatment
Approximately 40% had never received medical services in Thailand before (Table
5. 8). Nevertheless, almost 40% of them had come for medical treatment over several
visits. Most participants from long-haul regions were new customers to the hospitals,
while most of those from within region, had visited hospitals in Thailand before.
Half of them had received medical services in Thailand on more than three
occasions.
143
Table 5.8: History of medical services in Thailand by region
Long-haul regions Within region Total
Count % Count % Count %
Never before 66 71.7 47 25.0 113 40.4
Once or twice 15 16.3 37 19.7 52 18.6
More than 3 times 11 12.0 104 55.3 115 41.1
Total 92 100.0 188 100.0 280 100.0
2.3 Medical service package
The majority of participants, accounting for 70% of the total, had organised their
medical trip themselves (Table 5.9). However, participants from within versus long-
haul regions showed definite differences in the arrangements for their visit. Those
from long-haul regions tended to use medical service packages, while those from
within region tended to be self-organised.
Table 5.9: Type of medical service preparation by region
Long-haul regions Within region Total
Count % Count % Count %
Yes 80 86.0 6 3.0 86 29.4
No 13 14.0 194 97.0 207 70.6
Total 93 100.0 200 100.0 293 100.0
2.4 Total length of stay in Thailand
The largest group of participants, accounting for 44% of the total, stayed in Thailand
for between 8-14 days (Table 5.10). Participants from long-haul regions stayed for a
longer period than those from within region, approximately 12.8 and 11.9 days
respectively (Table 5.11).
144
Table 5.10: Length of stay of participants by region
Long-haul regions Within region Total
Count % Count % Count %
1-3 days 1 1.1 19 9.5 20 6.8
4-7 days 10 10.8 66 33.0 76 25.9
8-14 days 68 73.1 61 30.5 129 44.0
15-30 days 12 12.9 48 24.0 60 20.5
More than 30 days 2 2.2 6 3.0 8 2.7
Total 93 100.0 200 100.0 293 100.0
Table 5.11: Average length of stay of participants by region
Mean N Std.
Deviation
Minimum Maximum Median
Long-haul 12.88 93 10.956 2.00 105.00 10.00
Within region 11.96 200 11.102 1.00 90.00 10.00
Total 12.25 293 11.045 1.00 105.00 10.00
2.5 Number of companions
On their current trip, almost 50% of participants were travelling alone (Table 5.12).
A quarter was travelling with one companion. Participants from within region tended
to have more companions than those from long-haul regions.
Table 5.12: Number of companions by regions
Long-haul regions Within region Total
Count % Count % Count %
No companion 44 47.3 98 49.0 142 48.5
1 person 25 26.9 49 24.5 74 25.3
2 persons 17 18.3 26 13.0 43 14.7
3 persons 2 2.2 14 7.0 16 5.5
More than 3 persons 5 5.4 13 6.5 18 6.1
Total 93 100.0 200 100.0 293 100.0
145
5.3 Tourism expenditure
Numbers of international tourists have increased consistently with an average annual
increase of 7.51% [144]. The number of international tourists has increased from
11.5 million in 2005 to 22.3 million in 2012 [144]. This increase was as a result of
the growth of international tourists around the world and potential tourism
infrastructures in Thailand. International tourists have contributed a lot to the Thai
economy. Their revenues increased from 547.8 billion THB in 2007 to 983.9 billion
THB in 2012 (Table 5.13). Tourists from East Asia and Southeast Asia generated the
highest revenue, approximately 395.4 billion THB, followed by tourists from
Europe, Oceania and North America [144].
Table 5.13: Revenue from international tourists visiting Thailand from 2007-2012
Year Average expenditure
per tourist per day
(THB)
Total revenue
(Billion THB)
Total revenue
(Billion USD)
2007 4,120.95 547.7 15.8
2008 4,141.30 574.5 17.2
2009 4,011.21 510.3 14.8
2010 4,078.67 592.8 18.7
2011 4,178.12 776.2 25.4
2012 4,392.81 983.9 31.6
Source: MOTS
5.3.1 Tourism expenditures of medical tourists, their companions, and non-medical tourists.
1. Overall tourism expenditure
1.1 Actual tourism expenditure
Actual tourism expenditure in this section means all expenditures derived from
tourism activities, excluding health-related services. Medical tourists and their
companions tended to spend more on average on tourism elements than non-medical
tourists. The largest group of non-medical tourists, medical tourists and companions,
146
spent between 10,000-50,000 THB per visit, accounting for 75%, 34% and 50%
respectively (Table 5.14). Average actual tourism expenditure per medical tourist
visit was 2.6 times greater than the expenditure per visit of non-medical tourists,
approximately 82,520 THB and 31,970 THB respectively (Table 5.15). The average
expenditure of medical tourists’ companions was slightly lesser than that of the
medical tourists themselves, approximately 80,351 THB per visit (Table 5.15).
Table 5.14: Tourism expenditure of non-medical tourists, medical tourists and companions
Non-medical tourist Medical tourist Companion
Count % Count % Count %
Actual tourism expenditure
Less than 5,000 THB 558 2.0 28 9.7 4 3.2
5,001-10,000 THB 1,913 6.8 19 6.6 7 5.6
10,001-50,000 THB 21,100 75.3 99 34.4 50 39.7
50,000-100,000 THB 3,820 13.6 57 19.8 29 23.0
100,001-500,000 THB 617 2.2 82 28.5 34 27.0
500,000-1,000,000 THB - 0.0 3 1.0 2 1.6
More than 1,00,000 THB - 0.0 0 0.0 0 0.0
Total 28,008 100.0 288 100.0 126 100.0
Total expenditure Less than 5,000 THB 549 2.0 12 4.2 6 4.7
5,001-10,000 THB 1,895 6.8 6 2.1 5 3.9
10,001-50,000 THB 21,045 75.1 43 14.9 47 36.4
50,000-100,000 THB 3,869 13.8 65 22.6 31 24.0
100,001-500,000 THB 650 2.3 152 52.8 35 27.1
500,000-1,000,000 THB - 0.0 7 2.4 4 3.1
More than 1,00,000 THB - 0.0 3 1.0 1 0.8
Total 28,008 100.0 288 100.0 129 100.0
Table 5.15: Average tourism expenditure of non-medical tourists, medical tourists and companions
Type of patient Mean N Std. Deviation
Minimum Maximum Median
Actual tourism expenditure
Non-medical tourist 31,973.57 28,013 24,373.14 500.00 404,525.00 25,562.03
Medical tourist 82,522.92 288 94,843.29 - 702,000.00 49,110.00
Companion 80,351.92 126 83,923.77 86.00 517,500.30 52,150.00
Total expenditure
Non-medical tourist 32,285.84 28,013 24,968.49 500.00 404,525.00 25,700.00
Medical tourist 160,622.20 288 183,362.73 500.00 1,550,000.00 129,985.00
Companion 104,111.19 129 148,124.73 86.00 1,155,000.00 56,250.00
147
1.2 Total expenditure (including medical expenses)
Including medical spending under the heading of tourism expenditure altered
expenditure patterns (Table 5.14), increasing the largest category of expenditure of
medical tourists from between 10,000-50,000 THB to between 100,000-500,000
THB. The average expenditure of medical tourists increased from 82,522 THB to
160,622 THB (Table 5.15). Adding medical spending also affected the average
expenses of their companions, increasing it from 80,351 THB to 104,111 THB. Non-
medical tourists obviously spent less on healthcare services, so the inclusion of
medical spending made an insignificant increase to their average expenditure, from
31,970 THB to 32,280 THB (Table 5.15).
2. Regional comparison
2.1 Non-medical tourists
Tourists from long-haul regions spent more on tourism activities than those from
within the region (Table 5.16). Their average tourism expenditure per visit was
43,240 THB while the average of within region tourists was 24,920 THB (Table
5.17). Including medical spending in their overall expenditure didn’t change this
pattern, as tourists from both regions spent almost nothing on health services (Table
5.17).
148
Table 5.16: Tourism expenditure between non-medical tourists, medical tourists and companion by regions
Non-medical tourist Medical tourist Companion
Long-haul
Within Long-haul
Within Long-haul
Within
Actual tourism expense Less than 5,000 THB
Count 91 463 2 26 1 3
% 0.9% 2.7% 2.2% 13.2% 2.7% 3.4%
5,001-10,000 THB Count 289 1,596 5 14 1 6
% 2.8% 9.4% 5.5% 7.1% 2.7% 6.7%
10,001-50,000 THB Count 6,982 13,682 46 53 17 33
% 66.7% 80.6% 50.5% 26.9% 45.9% 37.1%
50,000-100,000 THB Count 2,646 1,095 25 32 8 21
% 25.3% 6.5% 27.5% 16.2% 21.6% 23.6%
100,001-500,000 THB Count 467 138 12 70 10 24
% 4.5% 0.8% 13.2% 35.5% 27.0% 27.0%
500,000-1,000,000 THB Count 0 0 1 2 0 2
% 0.0% 0.0% 1.1% 1.0% 0.0% 2.2%
More than 1,00,000 THB Count 0 0 0 0 0 0
% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Total Count 10,475 16,974 91 197 37 89
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Total expense Less than 5,000 THB Count 90 455 1 11 1 5
% 0.9% 2.7% 1.1% 5.6% 2.7% 5.4%
5,001-10,000 THB Count 285 1,582 1 5 1 4
% 2.7% 9.3% 1.1% 2.5% 2.7% 4.3%
10,001-50,000 THB Count 6,939 13,673
11
32
17
30
% 66.2% 80.5% 12.1% 16.2% 45.9% 32.6%
50,000-100,000 THB Count 2,670 1,117 15 50 8 23
% 22.5% 6.6% 16.5% 25.4% 21.6% 25.0%
100,001-500,000 THB Count 490 148 60 92 10 25
% 4.7% 0.9% 65.9% 46.7% 27.0% 27.2%
500,000-1,000,000 THB Count 0 0 2 5 0 4
% 0.0% 0.0% 2.2% 2.5% 0.0% 4.3%
More than 1,00,000 THB Count 0 0 1 2 0 1
% 0.0% 0.0% 1.1% 1.0% 0.0% 1.1%
Total Count 10,474 16,975 91 197 37 92
% 1.0 1.0 100.0% 100.0% 100.0% 100.0%
149
Table 5.17: Average tourism expenditure between non-medical tourists, medical tourists and companions by region
Type of patient
Region Mean N Std. Deviation
Minimum Maximum Median
Actual tourism
expenditure
Non-medical tourist
Long-haul 43,244.15 10,476 28,814.15 765.00 366,000.00 36,568.30
Within 24,919.08 16,978 17,976.98 500.00 404,525.00 20,590.07
Medical tourist
Long-haul 64,285.49 91 71,897.14 2,220.00 520,800.00 45,450.00
Within 90,947.31 197 102,821.43 0.00 702,000.00 54,500.00
Companion Long-haul 71,620.95 37 63,676.43 1,950.00 349,250.00 49,650.00
Within 83,981.66 89 91,106.70 86.00 517,500.30 53,500.00
Total expenditure Non-medical
tourist
Long-haul 43,716.97 10,476 29,561.84 765.00 366,000.00 36,870.00
Within 25,132.86 16,978 18,439.94 500.00 404,525.00 20,700.00
Medical tourist
Long-haul 179,273.41 91 179,485.48 2,880.00 1,450,800.00 155,460.00
Within 152,006.67 197 184,941.39 500.00 1,550,000.00 102,656.40
Companion Long-haul 72,320.68 37 64,145.61 1,950.00 349,250.00 49,650.00
Within 116,896.50 92 169,286.80 86.00 1,155,000.00 62,325.00
2.2 Medical tourists
In contrast, medical tourists from within-region tended to spend more on tourism
than those from long-haul regions; spending of between 100,000-500,000 THB
representing their biggest category of tourism expenses, while the largest for long-
haul patients was between 10,000-50,000 THB (Table 5.16). Average tourism
expenditure per trip of within-region patients was 90,950 THB, while for long-haul
patients it was 64,280 THB (Table 5.17). Adding medical expenditure to tourism
expenditure meant that medical tourists from long-haul regions had higher average
expenditure. The average expenditure, including medical spending, of long-haul
patients was 179,280 THB, while the average for within-region patients was 152,000
THB (Table 5.17). Average medical spending per trip of patients from long-haul
regions in this survey was 115,000 THB, whilst that of within region patients was
61,000 THB.
2.3 Companions
Similarly to the medical tourists, their companions from within region spent more on
tourism compared to companions from long-haul regions. The largest group of the
150
two regions spent between 10,000-50,000 THB per visit (Table 5.16). However,
average tourism expenditure per trip for companions from within region was 83,980
THB, while that for companions from long-haul regions was 71,620 THB (Table
5.17). In contrast to medical tourists, companions from within region tended to spend
more on healthcare services. An average expenditure including medical spending of
within-region companions was 166,900 THB, while that of long-haul companions
was 72,320 THB (Table 5.17). Average medical spending per trip of companions
from within region in this survey was 32,920 THB, while one from long-haul region
was much lower – approximately 700 THB.
3. Gender comparison
3.1 Non-medical tourists
There was very little difference in tourism expenditure and medical expenditure
between men and women among non-medical tourists (Table 5.18). Average actual
tourism expenditure for men and women was 32,400 THB and 31,320 THB
respectively (Table 5.19). Including spending on medical care had no influence on
these spending patterns. The average total expenditure for both men and women
slightly increased to 32,730THB and 31,605 THB respectively (Table 5.19).
151
Table 5.18: Tourism expenditure of non-medical and medical tourists, by gender
Non-medical tourist Medical tourist
Male Female Male Female
Actual tourism expenditure Less than 5,000 THB
Count 345 213 15 13
% 2.0% 1.9% 8.9% 10.8%
5,001-10,000 THB Count 1,170 743 8 11
% 6.9% 6.7% 4.8% 9.2%
10,001-50,000 THB Count 12,698 8,402 46 53
% 74.8% 76.2% 27.4% 44.2%
50,000-100,000 THB Count 2,338 1,482 29 28
% 13.8% 13.4% 17.3% 23.3%
100,001-500,000 THB Count 429 188 69 13
% 2.5% 1.7% 41.1% 10.8%
500,000-1,000,000 THB Count 0 0 1 2
% 0.0% 0.0% 0.6% 1.7%
More than 1,00,000 THB Count 0 0 0 0
% 0.0% 0.0% 0.0% 0.0%
Total Count 16,980 11,028 168 120
% 100.0% 100.0% 100.0% 100.0%
Total expenditure Less than 5,000 THB
Count 342 207 7 5
% 2.0% 1.9% 4.2% 4.2%
5,001-10,000 THB Count 1,156 739 3 3
% 6.8% 6.7% 1.8% 2.5%
10,001-50,000 THB Count 12,663 8,382 27 16
% 74.6% 76.0% 16.1% 13.3%
50,000-100,000 THB Count 2,365 1,504 37 28
% 13.9% 13.6% 22.0% 23.3%
100,001-500,000 THB Count 453 197 89 63
% 2.7% 1.8% 53.0% 52.5%
500,000-1,000,000 THB Count 0 0 3 4
% 0.0% 0.0% 1.8% 3.3%
More than 1,00,000 THB Count 0 0 2 1
% 0.0% 0.0% 1.2% 0.8%
Total Count 16,979 11,029 168 120
% 100.0% 100.0% 100.0% 100.0%
152
Table 5.19: Average tourism expenditure between non-medical tourists and medical tourists by gender
Type of patient
Gender Mean N Std. Deviation
Minimum Maximum Median
Actual tourism
expenditure
Non-medical tourist
Male 32,396.60 16,983 25,259.98 600.00 366,000.00 25,606.67
Female 31,322.21 11,030 22,926.61 500.00 404,525.00 25,521.23
Medical tourist
Male 98,872.52 168 97,077.91 0.00 702,000.00 68,478.75
Female 59,633.48 120 86,967.06 500.00 576,000.00 39,450.00
Total expenditure Non-medical
tourist
Male 32,727.77 16,983 25,969.75 600.00 366,000.00 25,781.60
Female 31,605.39 11,030 23,327.82 500.00 404,525.00 25,599.49
Medical tourist
Male 165,064.41 168 191,685.66 500.00 1,550,000.00 126,656.25
Female 154,403.11 120 171,630.33 1,550.00 1,450,800.00 129,985.00
3.2 Medical tourists
In contrast, there were noticeable differences in the spending levels of male and
female medical tourists. Male medical tourists spent more on tourism elements than
females (Table 5.18). The average tourism expenditure of the men was 98,870 THB,
while that of women was 59,630 THB – that of men being approximately 65%
higher (table5.19). The spending pattern between men and women also differed
slightly when medical spending was included (Table 5.18). The average total
expenditure of men and women was closer, approximately 165,060 THB and
154,400 THB respectively – an approximately 7% difference (Table 5.19). The
average medical spending of female patients in this survey was 94,800 THB per
patient per trip, while that of male patients was 66,200 THB – almost 40% higher.
Summary for tourism expenditure
Medical tourists engage not only in medical activities, but also considerably in
tourism. In terms of total expenditure per trip, they and their companions spent a lot
on these activities. Because the main purpose of their visits was medical care, they
spend much more on it when compared to non-medical tourists, as would be
expected. Yet they also spent far more than non-medical tourists on tourism
elements. Non-medical tourists from long-haul region spent more than those from
within region, but medical tourists and their companions from within region spent
153
more than those from long-haul regions. Male patients tended to spend more on
tourism elements, while female patients spent more on medical elements. In contrast,
gender did not influence the spending patterns of non-medical tourists.
5.3.2 Tourism spending profiles
Seven categories of spending, namely local transportation, accommodation, food &
drink, sightseeing, shopping, entertainment and other, were compared between non-
medical tourists, medical tourists and their respective companions. All categories
were adjusted to give the average spending per actual tourism day for the purposes of
comparison.
1. Overall tourism spending profiles
Medical tourists and their companions spent much more on tourism-related elements
compared to non-medical tourists. Average actual tourism expenditure per tourism
day of medical tourists was 8,440 THB, while that of their companions was 9,080
THB (Table 5.20); the actual tourism spending of non-medical tourists was 4,190
THB –around half that of the spending of medical tourists (Table 5.20). This implies
that medical tourists may be wealthier than non-medical tourists. Accommodation,
food & drink, and shopping accounted for most of the spending in all groups. These
three categories accounted for 70% of total expenses during stays in Thailand. The
average tourism expenditure of medical tourists’ companions was slightly greater
than that of the medical tourists themselves. They spent more on accommodation,
food and drink than medical tourists; the reason for this being that some of the
medical tourists’ expenditure on accommodation and food was included in their
medical expenses, while all that of the companions would come under the heading of
tourism expenditure. However, medical tourists spent more on shopping and
entertainment than their companions.
154
2. Regional comparison
2.1 Non-medical tourists
Tourism spending per day of tourists from within region was slightly more than that
of those from long-haul regions: 4,330 THB and 3,930 THB respectively (Table
5.21). In the main, they spent more in each category, particularly shopping.
2.2 Medical tourists and their companions
Medical tourists from within region had higher tourism expenditures than long-haul
patients: 9,480 THB and 6,200 THB respectively (Table 5.21). They also spent more
in all categories except accommodation. Similarly to medical tourists, companions
from within region spent more than those from long haul regions, accounting for
10,210 THB and 6,340 THB respectively (Table 5.21). The tourism spending profile
of companions was similar to that of medical tourists. Companions from within the
region spent more on all categories except accommodation.
3. Gender comparison
The tourism spending profiles of male and female non-medical tourists were
comparatively similar. Male tourists spent slightly more than female: 4,230 THB and
4,120 THB respectively (Table 5.22); but comparatively similar amounts in each
category. In the medical tourist category, males spent much more than females;
average tourism spending by men was 9,910 THB, approximately 50% more than the
6,400 THB spent by women (Table 5.22). Male patients tended to spend more in all
categories except accommodation.
155
Table 5.20: Tourism spending profiles per tourism day by non-medical tourists, medical tourists and companions
Type of patient Local transport/day
Accommodation/day
Food & Beverage/day
Sight-seeing/day
Shopping/day Entertainment/day
Other/day Actual tourism expense/day
Non-medical tourist
Mean 417.14 1,220.15 770.49 176.55 1,088.39 429.18 86.35 4,188.24
N 28,013 28,013 28,013 28,013 28,013 28,013 28,013 28,013
Std. Deviation 396.90 1,034.21 591.59 282.27 1,371.85 584.81 142.12 2,570.37
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 174.69
Maximum 12,500.00 49,500.00 12,000.00 7,234.36 30,000.00 12,120.00 4,950.00 67,420.83
Medical tourist Mean 671.46 2,467.14 1,211.53 415.69 2,119.45 933.19 168.18 8,443.58
N 287 287 287 287 287 287 287 287
Std. Deviation 949.97 3,959.99 1,264.87 714.71 3,155.09 4,770.22 955.33 9,743.52
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 96.88
Maximum 10,600.00 52,080.00 10,000.00 5,625.00 21,428.57 78,571.43 15,150.00 89,428.57
Companion Mean 740.55 2,526.33 1,675.32 556.95 1,680.25 483.87 310.98 9,082.24
N 127 127 127 127 127 127 127 127
Std. Deviation 905.85 2,406.83 4,559.34 922.77 2,433.65 1,268.88 1,546.72 12,799.98
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 86.00
Maximum 4,178.57 11,025.00 50,000.00 5,357.14 16,000.00 11,551.35 15,727.00 102,428.57
156
Table 5.21: Tourism spending profiles per tourism day by non-medical tourists, medical tourists and companions, by region
Type of patient Region Local transport/day
Accommodation/day
Food & Beverage/day
Sight-seeing/day
Shopping/day Entertainment/day
Other/day Actual tourism
expense/day Non-medical
tourist Long-haul Mean 441.86 1,197.51 783.85 171.04 853.90 415.88 67.92 3,931.96
N 10,476 10,476 10,476 10,476 10,476 10,476 10,476 10,476 Std. Deviation 379.09 977.15 610.09 255.22 1,198.64 593.19 128.66 2,507.88 Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 174.69 Maximum 5,656.88 14,000.00 10,000.00 3,134.55 29,750.00 9,566.67 4,120.00 38,150.00
Within Mean 401.54 1,233.52 761.59 180.62 1,220.37 439.41 97.59 4,334.64 N 16,978 16,978 16,978 16,978 16,978 16,978 16,978 16,978 Std. Deviation 407.94 1,073.82 580.12 298.22 1,434.50 581.18 148.94 2,594.40 Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 192.86 Maximum 12,500.00 49,500.00 12,000.00 7,234.36 30,000.00 12,120.00 4,950.00 67,420.83
Medical tourist Long-haul Mean 313.67 3,140.71 755.93 221.45 1,477.78 278.42 20.62 6,208.58 N 91 91 91 91 91 91 91 91 Std. Deviation 539.83 5,604.41 681.51 354.96 2,514.12 499.94 99.09 6,433.27 Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 240.00 Maximum 4,132.50 52,080.00 3,333.33 1,875.00 21,000.00 3,099.00 600.00 52,080.00
Within Mean 837.58 2,154.42 1,423.06 505.87 2,417.37 1,237.19 236.69 9,481.26 N 196 196 196 196 196 196 196 196 Std. Deviation 1,049.57 2,862.32 1,410.78 815.64 3,376.60 5,741.57 1,148.55 10,803.91 Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 96.88 Maximum 10,600.00 22,500.00 10,000.00 5,625.00 21,428.57 78,571.43 15,150.00 89,428.57
Companion Long-haul Mean 400.27 3,213.74 778.61 488.35 1,116.22 302.10 36.86 6,336.15 N 37 37 37 37 37 37 37 37 Std. Deviation 628.72 2,581.14 627.70 691.32 1,140.07 385.30 139.11 3,992.89 Minimum 0.00 0.00 43.04 0.00 0.00 0.00 0.00 325.00 Maximum 3,262.11 11,025.00 2,500.00 3,333.33 5,812.50 1,427.14 600.00 17,525.00
Within Mean 880.44 2,243.72 2,043.97 585.16 1,912.13 558.60 423.67 10,211.18 N 90 90 90 90 90 90 90 90 Std. Deviation 966.38 2,286.71 5,366.42 1,004.71 2,769.93 1,483.24 1,826.20 14,868.75 Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 86.00 Maximum 4,178.57 10,442.86 50,000.00 5,357.14 16,000.00 11,551.35 15,727.00 102,428.57
157
Table 5.22: Tourism spending profiles per tourism day by non-medical tourists and medical tourists by gender
Type of patient Gender Local transport/day
Accommodation/day
Food & Beverage/day
Sight-seeing/day
Shopping/day Entertainment/day
Other/day Actual tourism expense/day
Non-medical tourist
Male Mean 421.11 1,242.91 786.26 169.12 1,065.04 458.68 85.98 4,229.10
N 16,983 16,983 16,983 16,983 16,983 16,983 16,983 16,983
Std. Deviation
407.53 995.18 609.72 289.94 1,411.05 646.66 142.04 2,594.69
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 174.69
Maximum 12,500.00 20,000.00 12,000.00 7,234.36 30,000.00 12,120.00 3,032.00 38,150.00
Female Mean 411.02 1,185.12 746.20 187.99 1,124.34 383.75 86.91 4,125.32
N 11,030 11,030 11,030 11,030 11,030 11,030 11,030 11,030
Std. Deviation
379.91 1,090.70 561.70 269.64 1,308.46 470.47 142.25 2,531.29
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 192.86
Maximum 9,654.17 49,500.00 9,400.00 3,910.20 22,750.00 6,666.67 4,950.00 67,420.83
Medical tourist Male Mean 939.44 2,245.91 1,561.42 611.66 2,629.79 1,008.20 280.34 9,914.48
N 167 167 167 167 167 167 167 167
Std. Deviation
1,092.62 2,929.52 1,459.81 855.71 3,238.08 1,532.22 1,240.48 9,417.17
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 100.00
Maximum 10,600.00 22,500.00 10,000.00 5,625.00 16,666.67 6,750.00 15,150.00 64,265.05
Female Mean 298.52 2,775.02 724.61 142.96 1,409.22 828.81 12.09 6,396.58
N 120 120 120 120 120 120 120 120
Std. Deviation
512.40 5,054.94 679.35 278.08 2,902.40 7,169.01 68.48 9,858.74
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 96.88
Maximum 4,132.50 52,080.00 3,333.33 1,392.86 21,428.57 78,571.43 600.00 89,428.57
158
4. Statistical analysis
Two independent sample T-tests were employed to test whether there was any
statistically significant difference in the average expenditure in each spending
category between non-medical tourists VS medical tourists and non-medical tourists
VS medical tourists’ companions. The null hypothesis was that there is no difference
in spending between the two groups. Considerable difference (p value < 0.0001) in
average expenditure was found in all categories except those of entertainment and
‘other expenses’, between non-medical tourists and medical tourists (Table 5.23).
Comparisons between non-medical tourists and companion show a substantial
difference (p value < 0.0001) in spending on local transportation, accommodation
and sightseeing, while there was difference in spending on food (p value = 0.027)
and shopping (p value 0.007) (Table 5.24). Meanwhile, there was no difference in
spending on entertainment (p value = 0.628) or in the ‘other spending’ category (p
value = 0.104) (Table 5.24).
Table 5.23: Comparison of expenditure by non-medical tourists and medical tourists, by tourism spending item
Type of patient N Mean 95% CI p value
Lower Upper
Local transport Medical tourist 287 671.46 143.86 364.79 < 0.0001
Non-medical tourist 28,013 417.14
Accommodation Medical tourist 287 2,467.14 786.74 1,707.24 < 0.0001
Non-medical tourist 28,013 1,220.15
Food Medical tourist 287 1,211.53 293.93 588.17 < 0.0001
Non-medical tourist 28,013 770.49
Sightseeing Medical tourist 287 415.69 156.04 322.24 < 0.0001
Non-medical tourist 28,013 176.55
Shopping Medical tourist 287 2,119.45 664.13 1,397.98 < 0.0001
Non-medical tourist 28,013 1,088.39
Entertainment Medical tourist 287 933.19 -50.25 1,058.28 0.075
Non-medical tourist 28,013 429.18
Other expense Medical tourist 287 168.18 -29.17 192.84 0.148
Non-medical tourist 28,013 86.35
Actual tourism expense
Medical tourist 287 8,443.58 3,122.90 5,387.79 < 0.0001
Non-medical tourist 28,013 4,188.24
159
Table 5.24: Comparison of expenditure by non-medical tourists and medical tourist’s companions, by tourism item
Type of patient N Mean 95% CI p value
Lower Upper
Local transport Companion 127 740.55 164.28 482.55 < 0.0001
Non-medical tourist 28,013 417.14
Accommodation Companion 127 2,526.33 883.35 1,729.00 < 0.0001
Non-medical tourist 28,013 1,220.15
Food Companion 127 1,675.32 104.16 1,705.51 0.027
Non-medical tourist 28,013 770.49
Sightseeing Companion 127 556.95 218.33 542.48 < 0.0001
Non-medical tourist 28,013 176.55
Shopping Companion 127 1,680.25 164.20 1,019.52 0.007
Non-medical tourist 28,013 1,088.39
Entertainment Companion 127 483.87 -168.23 277.62 0.628
Non-medical tourist 28,013 429.18
Other expense Companion 127 310.98 -46.99 496.25 0.104
Non-medical tourist 28,013 86.35
Actual tourism expense
Companion 127 9,082.24 2,646.06 7,141.94 < 0.0001
Non-medical tourist 28,013 4,188.24
160
5.3.3 Influencing factors on actual tourism expenditure
Tourism is very important to destination economies, through spending on a variety of
tourism elements, as described in the previous section. To increase tourism revenues,
many strategies have been established, in order to increase the number of tourists and
lengthen their periods of stay. Increasing tourism spending per day is one of the
elements taken into account by tourism policy makers. Many contributing factors
affect tourist spending, such as age, gender, and type of accommodation.
To assess the influencing factors on actual tourism expenditure per day, variables
related to socio-demographic and travel-related elements are postulated as an
equation. Socio-demographic variables include gender, region of origin, age and
annual income, whereas travel-related variables include length of stay in Thailand.
The interest is in whether being medical tourist influences tourism expenditure, and
to what extent, compared to other factors. Thus, a variable reflecting the fact of being
a medical tourist is posited in the equation as well.
When the six predictor variables were modelled together, all variables were
significant (Table 5.25). Five of the variables: being a medical tourist, region, age,
income level and length of stay in Thailand were highly significant (p value <
0.0001) while gender was significant at p value 0.005. The R squared of overall
formula is 0.154.
Being a medical tourist, region of origin, gender, age, income level and length of stay
are contributing factors to actual tourism spending per day. Being a medical tourist,
being a traveller from a long-haul region, and being female all tend to increase actual
tourism expenditure per day. Older travellers and those with a higher income level
also tend to spend more. However, the longer the length of stay, the less spent per
day. Of all the variables, being a medical tourist has the strongest influence on
tourism expenditure per day (Table 5.25).
161
Table 5.25: Influencing factors on tourism expenditure
Variable Category N Means Standard deviation
Co-efficient 95% CI Overall p value
lower upper
1. Type of tourists < 0.0001
Non-medical tourist * 28,013 4,188.24 2,570.367 0.245 0.216 0.274
Medical tourist 293 8,270.68 9,717.011
2. Region < 0.0001
Long-haul 10,569 3,950.82 2,575.607 0.022 0.016 0.029
Within * 17,178 4,392.35 2,877.662
3. Gender 0.005
Male 17,152 4,283.96 2,799.681 -0.008 -0.014 -0.002
Female * 11,154 4,148.27 2,726.598
4. Age group < 0.0001
Less than 25 * 5,238 3,713.76 2,483.363
25-34 10,890 4,185.67 2,590.874 0.024 0.016 0.032
35-44 6,806 4,489.43 2,922.576 0.035 0.026 0.044
45-54 3,696 4,539.62 2,749.067 0.032 0.021 0.042
55-64 1,335 4,458.20 3,197.221 0.037 0.022 0.051
More than 65 341 4,189.38 5,449.398 0.010 -0.016 0.036
5. Annual income < 0.0001
Less than 20,000 USD *
10,582 3,861.83 2,633.260
20,000-39,999 USD 9,492 4,210.84 2,613.287 0.037 0.030 0.044
40,000-59,999 USD 4,618 4,526.66 2,869.719 0.073 0.065 0.082
60,000-79,999 USD 1,828 4,719.11 3,048.752 0.096 0.084 0.109
More than 80,000 USD 1,742 5,282.07 3,334.900 0.132 0.120 0.144
6. Length of stay in Thailand
< 0.0001
1-3 days * 3,554 5,177.20 3,671.795
4-7 days 13,265 4,600.29 2,694.529 -0.019 -0.027 -0.010
8-14 days 7,175 3,909.14 2,343.065 -0.114 -0.124 -0.104
15-31 days 3,820 2,937.72 2,074.438 -0.249 -0.261 -0.238
More than 30 days 492 2,145.39 2,546.977 -0.398 -0.420 -0.376
R square = 0.154
162
5.4 Medical expenditure
5.4.1Comparison between medical tourists and Thai private patients
1. Overall medical expenditure
The individual medical expenditure of medical tourists was higher than that of Thai
private patients. For out-patient expenses, the largest group of medical tourists,
approximately 44%, spent between 10,000 and 50,000 THB, while the largest group
of Thai patients, approximately 50%, spent less than 5,000 THB (Table 5.26).
Medical tourist spend for OP expenses was around 24,520 THB on average,
approximately 60% higher than the 15,280 THB spent by Thai private patients (Table
5.27). Medical tourists and Thai patients spent much more on in-patient care than on
out-patient expenses. Nearly 60% of medical tourists spent between 100,000-500,000
THB on in-patient care, while 54% of Thai patients spent between 10,000-50,000
THB (Table 5.26). The average IP expenses of medical tourists were 353,460 THB –
14-times greater than their OP expenses (Table 5.27). Average IP expenses for Thai
patients were 120,880 THB.
Though foreign patients tended to spend more than Thais, domestic patients still
generated more revenue in total. In 2010, total revenue from Thai private patients in
the five hospitals was 13.7 billion THB, while medical tourists generated revenues of
5.2 billion THB – approximately 2.6 times less (Table 5.28). Among foreign patients,
medical tourists generated more revenue than other categories.
163
Table 5.26: Medical expenditure by medical tourists and Thai private patients
OP expense IP expense Total expense
Medical
tourists
Thai private
patients
Medical
tourists
Thai
patients
Medical
tourists
Thai
patients
Less than 5,000 THB Count 32,284 248,977 29 366 29,809 237,132
% 31.1% 50.8% .3% .7% 28.5% 47.7%
5,001-10,000 THB Count 14,598 83,114 20 1359 13,861 77,370
% 14.0% 17.0% .2% 2.6% 13.3% 15.6%
10,001-50,000 THB Count 45,651 129,029 964 27,646 43,741 131,664
% 43.9% 26.3% 11.5% 53.4% 41.9% 26.5%
50,001-100,000 THB Count 8,177 19,148 1,159 9,434 8,068 26,869
% 7.9% 3.9% 13.8% 18.2% 7.7% 5.4%
100,001-500,000 THB Count 3,105 9,549 4,913 10,732 7,492 21,012
% 3.0% 1.9% 58.5% 20.7% 7.2% 4.2%
500,001-1,000,000 THB Count 89 363 818 1,435 981 2,126
% .1% .1% 9.7% 2.8% .9% .4%
More than 1,000,000 THB Count 17 122 492 810 522 1,092
% .0% .0% 5.9% 1.6% .5% .2%
Total Count 103,921 490,302 8,395 51,782 104,474 497,265
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Table 5.27: Average medical expenditure by medical tourists and Thai private patients
Type of patient Mean N Std.
Deviation
Minimum Maximum Median
OP expense Medical tourists 24,519.73 103,921 45,127.13 0 3,186,743 12,853.00
Thai patients 15,276.39 490,302 62,837.61 0 29,091,814 4,876.00
IP expense Medical tourists 353,462.21 8,395 752,515.02 0 20,327,593 188,007.00
Thai patients 120,875.70 51,782 337,739.59 0 15,845,296 40,801.90
Total expense Medical tourists 50,410.27 104,474 216,325.90 0 17,218,794 15,519.00
Thai patients 27,649.71 497,265 137,233.32 0 29,091,814 5,552.45
Table 5.28: Total revenue by type of patient in the five hospitals in 2010
Type of patients Number of patients Total revenue %
Thai 497,265 13,749,231,765.78 53.44
Medical tourists 104,474 5,266,562,054.95 20.47
Expatriates 73,976 3,509,505,659.19 13.64
Sick foreign travellers 57,626 3,201,036,218.36 12.44
Total 733,341 25,726,335,698.00 100.0
164
2. Gender comparison
2.1 Out-patient (OP) expense
There was similar pattern in OP expenditure between men and women among
medical tourists and Thai patients (Table 5.29). The largest group of male and female
medical tourists paid between 10,000-50,000 THB, while the largest group of Thai
patients paid less than 5,000 THB (Table 5.29). Average OP expenditure of female
medical tourists was slightly higher than that of male medical tourists –
approximately 25,490 THB and 23,820 THB respectively (Table 5.30). Average OP
expense of female and male Thai patients was a comparatively similar amount –
approximately 15,280 THB and 15,180 THB respectively (Table 5.34).
2.2 In-patient (IP) expense
There was more difference between male and female spending on IP expenses than
on OP expenses. Most male and female medical tourists paid between 100,000 and
500,000 THB, while most Thai patients paid between 10,000 and 50,000 THB (Table
5.29). Male patients in both medical tourist and Thai groups spent more than female
patients in regards to services required and longer stays in hospital. Average IP
expenditure of male medical tourists was 387,100 THB - 20% greater than that of
females (Table 5.30). The average IP expenditure of male Thai patients was 141,440
THB – approximately 30% greater than that of females (Table 5.30).
165
Table 5.29: Medical expenditure by medical tourists and Thai private patients by gender
Medical tourists Thai private patients
Male Female Male Female
OP expenditure Less than 5,000 THB Count 19,008 13,267 102,205 146,642
% 31.6% 30.4% 52.1% 49.9%
5,001-10,000 THB Count 8,425 6,170 32,448 50,623
% 14.0% 14.1% 16.5% 17.2%
10,001-50,000 THB Count 26,621 19,024 49,756 79,199
% 44.2% 43.6% 25.4% 26.9%
50,001-100,000 THB Count 4,428 3,749 7,571 11,543
% 7.4% 8.6% 3.9% 3.9%
100,001-500,000 THB Count 1,693 1,410 3,900 5,629
% 2.8% 3.2% 2.0% 1.9%
500,001-1,000,000 THB Count 47 42 150 208
% 0.1% 0.1% 0.1% 0.1%
More than 1,000,000
THB
Count 8 9 50 70
% 0.0% 0.0% 0.0% 0.0%
Total Count 60,230 43,671 196,080 293,914
% 100.0% 100.0% 100.0% 100.0%
IP expenditure Less than 5,000 THB Count 16 13 129 237
% 0.4% 0.3% 0.6% 0.8%
5,001-10,000 THB Count 8 12 561 798
% 0.2% 0.3% 2.7% 2.6%
10,001-50,000 THB Count 581 383 11,000 16,644
% 13.6% 9.3% 53.2% 53.5%
50,001-100,000 THB Count 657 502 3,683 5,751
% 15.4% 12.1% 17.8% 18.5%
100,001-500,000 THB Count 2,186 2,726 4,106 6,622
% 51.3% 66.0% 19.9% 21.3%
500,001-1,000,000 THB Count 479 339 742 693
% 11.2% 8.2% 3.6% 2.2%
More than 1,000,000
THB
Count 334 158 459 351
% 7.8% 3.8% 2.2% 1.1%
Total Count 4,261 4,133 20,680 31,096
% 100.0% 100.0% 100.0% 100.0%
166
Table 5.30: Average medical expenditure by medical tourists and Thai private patients, by gender
Gender Type of
patient
Mean N Std.
Deviation
Minimum Maximum Median
OP
expenditure
Medical
tourist
Male 23,815.58 60,230 43,380.07 - 3,027,182 12,700.00
Female 25,489.83 43,671 47,412.97 - 3,186,743 13,237.00
Thai
patients
Male 15,184.17 196,080 82,538.12 - 29,091,814 4,602.90
Female 15,283.70 293,914 43,399.89 - 4,353,816 5,025.00
IP
expenditure
Medical
tourist
Male 387,096.51 4,261 783,418.38 - 17,192,393.80 177,939.73
Female 318,846.77 4,133 717,799.99 - 20,327,593.30 193,033.00
Thai
patients
Male 141,439.02 20,680 388,737.02 - 9,402,831.00 40,520.03
Female 107,203.23 31,096 298,305.97 - 15,845,295.95 40,953.50
3. Age group comparison
3.1 Out-patient (OP) expense
Table 5.31 shows that the older patients were, the more they paid. The average OP
expense of patients aged under 25 in both medical tourist and Thai patient categories
was approximately 10,000 THB per patient (Table 5.31). OP expenditure increased to
35,000 THB per patient among those aged over 65. The expenditure of medical
tourists was higher than Thai patients in every age group. However, expenditure in
both groups became closer in patients over 65 (Table 5.32).
3.2 In-patient (IP) expense
The distribution of IP expenditure among age groups was fairly similar in medical
tourists and Thai patients (Table 5.33). Table 5.33 shows that the older patients were,
the more they paid, as with OP expenditure. The range of medical tourist IP
expenditures was between 231,500 THB in patients under 25 and 610,620 THB in
patients over 65 – approximately 2.6 times more (Table 5.34). IP expense in Thai
patients was much lower than that of medical tourists but covered a greater range.
The lowest average expense was 54,620 THB in patients under 25, while the highest
was 272,700 THB in patients over 65 – approximately 5 times more (Table 5.34).
167
Thai patients had greater cost flexibility than medical tourists, as they generally had
less serious diseases requiring less intensive care.
In terms of age group, the older patients were the more they paid in both OP and IP
expenditure categories. Medical tourists spent more than Thai patients on OP
services in every age group, but the average expenditure became closer in patients
over 65. Medical tourists also spent more than Thai patients on IP services in every
age group.
168
Table 5.31: Out-patient expenditure by medical tourists and Thai private patients, by age group
Age group
Medical tourists Thai private patients
Less
than 25
25-34 35-44 45-54 55-64 More
than 65
Less
than 25
25-34 35-44 45-54 55-64 More
than 65
Less than 5,000 THB Count 7,679 7,224 6,252 5,142 3,716 2,261 63,354 69,730 50,786 31,313 19,130 14,663
% 50.5% 36.7% 27.6% 23.7% 23.9% 25.0% 56.8% 60.3% 51.3% 43.7% 38.9% 33.8%
5,001-10,000 THB Count 2,951 3,216 3,177 2,542 1,723 985 20,727 19,479 17,604 11,984 7,423 5,897
% 19.4% 16.3% 14.0% 11.7% 11.1% 10.9% 18.6% 16.8% 17.8% 16.7% 15.1% 13.6%
10,001-50,000 THB Count 4,076 8,153 11,133 11,055 7,310 3,920 25,150 23,499 25,896 22,425 16,823 15,236
% 26.8% 41.4% 49.1% 50.9% 47.1% 43.4% 22.6% 20.3% 26.2% 31.3% 34.2% 35.1%
50,001-100,000 THB Count 370 790 1,574 2,230 1,969 1,244 1,831 2,243 3,263 3,955 3,675 4,181
% 2.4% 4.0% 6.9% 10.3% 12.7% 13.8% 1.6% 1.9% 3.3% 5.5% 7.5% 9.6%
100,001-500,000 THB Count 141 309 535 736 781 603 388 758 1,342 1,812 2,029 3,220
% 0.9% 1.6% 2.4% 3.4% 5.0% 6.7% 0.3% 0.7% 1.4% 2.5% 4.1% 7.4%
500,001-1,000,000 THB Count 3 8 15 20 32 11 9 16 36 64 81 157
% 0.0% 0.0% 0.1% 0.1% 0.2% 0.1% 0.0% 0.0% 0.0% 0.1% 0.2% 0.4%
More than 1,000,000 THB Count - 1 3 8 3 2 6 3 10 23 20 60
% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.1%
Total Count 15,220 19,701 22,689 21,733 15,534 9,026 111,465 115,728 98,937 71,576 49,181 43,414
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
169
Table 5.32: Average out-patient expenditure by medical tourists and Thai private patients, by age group
Age group Mean N Std. Deviation Minimum Maximum Median
Medical tourists Less than 25 11,463.55 15,220 23,363.51 0 837,708 4,911.00
25-34 17,712.83 19,701 31,379.93 0 1,213,605 8,821.00
35-44 24,045.73 22,689 42,246.48 0 3,186,743 15,300.00
45-54 29,423.56 21,733 50,958.21 0 2,318,569 18,766.00
55-64 33,399.01 15,534 57,976.64 0 3,027,182 20,479.50
More than 65 35,530.62 9,026 56,121.68 0 1,293,485 20,218.90
Total 24,522.79 103,903 45,130.27 0 3,186,743 12,860.00
Thai private patients Less than 25 9,249.78 111,465 92,323.16 0 29,091,814 3,908.00
25-34 9,276.31 115,728 22,520.82 0 2,658,768 3,465.05
35-44 13,192.72 98,937 32,595.12 0 2,405,099 4,781.20
45-54 18,741.78 71,576 49,484.93 0 3,732,679 6,487.00
55-64 24,170.72 49,181 56,295.01 0 2,251,681 8,376.00
More than 65 35,703.70 43,414 102,876.85 0 7,418,924 11,279.31
Total 15,276.42 490,301 62,837.67 0 29,091,814 4,876.00
170
Table 5.33: In-patient expenditure by medical tourists and Thai private patients, by age group
Age group
Medical tourists Thai private patients
Less
than 25
25-34 35-44 45-54 55-64 More
than 65
Less
than 25
25-34 35-44 45-54 55-64 More
than 65
Less than 5,000 THB Count 17 4 - 6 1 1 106 72 60 40 38 50
% 1.6% 0.3% 0.0% 0.4% 0.1% 0.1% 0.7% 0.8% 0.8% 0.6% 0.7% 0.6%
5,001-10,000 THB Count 7 3 2 2 5 1 786 209 139 93 69 63
% 0.6% 0.2% 0.1% 0.1% 0.3% 0.1% 5.2% 2.3% 1.8% 1.5% 1.3% 0.7%
10,001-50,000 THB Count 244 129 144 170 147 130 10,479 5,105 3,995 2,978 2,274 2,815
% 22.4% 10.3% 10.4% 10.5% 9.6% 8.6% 69.6% 56.3% 50.8% 48.2% 43.9% 33.3%
50,001-100,000 THB Count 212 179 214 243 165 146 2,308 1,790 1,608 1,210 966 1,552
% 19.4% 14.3% 15.5% 15.0% 10.7% 9.7% 15.3% 19.8% 20.5% 19.6% 18.6% 18.4%
100,001-500,000 THB Count 536 879 905 957 883 753 1,244 1,797 1,903 1,561 1,428 2,799
% 49.2% 70.0% 65.5% 59.1% 57.5% 49.8% 8.3% 19.8% 24.2% 25.3% 27.5% 33.2%
500,001-1,000,000 THB Count 42 46 94 162 221 253 88 60 109 196 287 695
% 3.9% 3.7% 6.8% 10.0% 14.4% 16.7% 0.6% 0.7% 1.4% 3.2% 5.5% 8.2%
More than 1,000,000 THB Count 32 16 23 80 114 227 48 30 44 98 122 468
% 2.9% 1.3% 1.7% 4.9% 7.4% 15.0% 0.3% 0.3% 0.6% 1.6% 2.4% 5.5%
Total Count 1,090 1,256 1,382 1,620 1,536 1,511 15,059 9,063 7,858 6,176 5,184 8,442
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
171
Table 5.34: Average in-patient expenditure by medical tourists and Thai private patients, by age group
Age group Type of patient Mean N Std. Deviation Minimum Maximum Median
Medical tourists Less than 25 231,458.86 1,090 636,720.53 0 13,150,029.70 118,630.75
25-34 207,892.77 1,256 299,546.94 0 6,228,379.00 166,274.50
35-44 238,244.93 1,382 324,344.53 5,667.00 5,908,664.00 173,894.50
45-54 339,636.45 1,620 638,379.36 0 9,365,116.00 190,623.50
55-64 424,344.08 1,536 840,533.44 608.00 16,735,084.24 220,111.00
More than 65 610,624.57 1,511 1,190,626.04 0 20,327,593.30 293,849.60
Total 353,462.21 8,395 752,515.02 608.00 20,327,593.30 188,007.00
Thai patients Less than 25 54,625.20 15,059 167,238.59 0 6,750,146.59 27,646.00
25-34 74,540.28 9,063 138,041.28 0 4,223,883.31 38,745.70
35-44 95,534.21 7,858 252,563.00 0 10,810,010.50 44,917.67
45-54 135,067.23 6,176 331,416.04 0 8,432,491.02 49,456.97
55-64 168,596.43 5,184 368,867.82 0 8,469,350.00 57,598.64
More than 65 272,700.68 8,442 608,925.24 0 15,845,295.95 88,339.34
Total 120,875.70 51,782 337,739.59 0 15,845,295.95 40,801.90
172
4. Statistical analysis
A two independent sample T-test was employed to test whether there was any
difference in average OP and IP expenditures between medical tourists and Thai
private patients. The null hypothesis was that there was no difference between the
two groups. There was a considerable significant difference (p value < 0.0001) in
both OP and IP expenditures between medical tourists and Thai patients (Table 5.35).
In order to test for differences in expenditure according to the gender of medical
tourists, a two independent sample T-test was also employed. The null hypothesis
was that there is no difference in expenditure between genders of medical tourists. A
considerable significant difference (p value < 0.0001) was found in both OP and IP
expenditure between the genders of medical tourists (Table 5.36).
Table 5.35: Comparison of medical expenditure by medical tourists and Thai private patients
Means N 95% CI p value
Lower Upper
Total OP
expenditure
Medical tourists 24,519.73 103,921 8,840.95 9,645.72 < 0.0001
Thai private patients 15,276.39 490,302
Total IP
expenditure
Medical tourists 353,462.21 8,395 222,880.50 242,292.52 < 0.0001
Thai private patients 120,875.70 51,782
Table 5.36: Comparison of medical expenditure by medical tourists, by gender
Means N 95% CI p value
Lower Upper
Total OP expense Male 23,815.58 60,230 -2,230.05
-1,118.45
< 0.0001
Female 25,489.83 43,671
Total IP expense Male 387,096.51 4,261 36,074.34 100,425.13 < 0.0001
Female 318,846.77 4,133
173
5.4.2 Medical expenditure: Regional comparison
1. Overall picture
This section demonstrates a comparison of medical expenditure between two
categories of region. The first group comprises long-haul regions, including Europe,
North America, Australia and Oceania. The second group comprises within-region
countries, including those in Southeast Asia, South Asia, East Asia and the Middle
East.
1.1 Out-patient (OP) expenditure
Medical tourists from within region tended to spend more than those from long-haul
regions. Almost 50% of within-region patients spent between 10,000-50,000 THB
on OP expenses, while 44% of long-haul patients spent less than 5,000 THB (Table
5.37). Average OP expenditure of within-region patients was 25,380 THB, while
long-haul patients spent 20,690 THB (Table 5.38).
1.2 In-patient (IP) expenditure
Table 5.37 shows that the pattern of IP expenditure between patients from long-haul
and within-region was comparatively similar. However, patients from within-region
spent more than those from long-haul regions as their hospital stays were typically
longer, as described in the previous chapter. Average IP expenditures in patients
from within-region and long-haul regions were 396,740 THB and 277,360 THB
respectively (Table 5.38).
174
Table 5.37: Medical expenditure of medical tourists, by regions
OP expenditure IP expenditure
Long-haul Within Long-haul Within
Less than 5,000 THB Count 11,848 19,028 15 12
% 44.0% 26.5% .5% .3%
5,001-10,000 THB Count 3,701 10,272 8 11
% 13.7% 14.3% .3% .2%
10,001-50,000 THB Count 8,919 34,376 343 581
% 33.1% 47.9% 10.9% 12.2%
50,001-100,000 THB Count 1,637 5,981 392 701
% 6.1% 8.3% 12.4% 14.7%
100,001-500,000 THB Count 807 2,034 2,021 2,609
% 3.0% 2.8% 64.1% 54.9%
500,001-1,000,000 THB Count 20 58 272 483
% .1% .1% 8.6% 10.2%
More than 1,000,000 THB Count 7 8 100 357
% .0% .0% 3.2% 7.5%
Total Count 26,939 71,757 3,151 4,754
% 100.0% 100.0% 100.0% 100.0%
Table 5.38: Average medical expenditure of medical tourists, by region
Region Mean N Std.
Deviation
Minimum Maximum Median
OP expense Long-haul 20,692.99 26,939 47,732.67 0 3,186,743 6,812.00
Within 25,384.20 71,757 42,680.76 0 3,027,182 15,477.00
IP expense Long-haul 277,363.50 3,151 392,236.57 0 8,07,5947 196,585.00
Within 396,739.09 4,754 895,681.96 0 20,327,593 175,955.50
2. Gender comparison
2.1 Out-patient (OP) expenditures
Patterns of OP expenditure between male and female patients from long-haul and
within-region were similar (Table 5.39). The average OP expenditures of male and
female patients from long-haul regions were only slightly different – approximately
20,800 THB and 20,460 THB respectively (Table 5.40). The average expenditure of
female patients from within-region was slightly higher than the average of male
patients: approximately 26,570 THB and 24,450 THB respectively.
2.2 In-patient (IP) expenditure
175
Patterns of IP expenditure tended to differ more than those of OP expenditures
between male and female patients. Most patients from both groups spent between
100,000-500,000 THB (Table 5.39), but in each group male patients spent more than
female patients (Table 5.40).
In terms of gender, there was no difference in OP expenditures by male and female
patients in either long-haul or within-region groups, but male patients spent more
than female patients on IP services in both groups.
Table 5.39: Medical expenditure of medical tourists between regions, by gender
OP expense IP expense
Long-haul Within Long-haul Within
Male Female Male Female Male Female Male Female
Less than 5,000 THB Count 7,362 4,484 10,909 8,113 9 6 7 5
% 43.0% 45.7% 27.2% 25.7% .7% .3% .3% .2%
5,001-10,000 THB Count 2,334 1,366 5,742 4,530 3 5 4 7
% 13.6% 13.9% 14.3% 14.3% .2% .3% .2% .3%
10,001-50,000 THB Count 5,837 3,080 19,370 15,002 185 158 368 213
% 34.1% 31.4% 48.3% 47.5% 13.4% 8.9% 14.2% 9.8%
50,001-100,000 THB Count 1,055 582 3,044 2,937 224 168 393 308
% 6.2% 5.9% 7.6% 9.3% 16.2% 9.5% 15.2% 14.2%
100,001-500,000 THB Count 511 294 1,033 1,001 756 1,264 1,275 1,334
% 3.0% 3.0% 2.6% 3.2% 54.8% 71.4% 49.2% 61.6%
500,001-1,000,000 THB Count 10 10 37 21 124 148 309 174
% .1% .1% .1% .1% 9.0% 8.4% 11.9% 8.0%
More than 1,000,000
THB
Count 4 3 2 6 78 22 233 124
% .0% .0% .0% .0% 5.7% 1.2% 9.0% 5.7%
Total Count 17,113 9,819 40,137 31,610 1,379 1,771 2,589 2,165
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Table 5.40: Average medical expenditure of medical tourists between regions, by gender
Region Gender Mean N Std.
Deviation
Minimum Maximum Median
OP
expenditure
Long-haul Male 20,809.94 17,113 44,137.09 0 1,861,343 7,195.00
Female 20,465.37 9,819 53,399.02 0 3,186,743 6,224.00
Within Male 24,453.41 40,137 41,649.53 0 3,027,182 15,299.00
Female 26,569.64 31,610 43,932.53 0 2,318,569 16,304.50
IP
expenditure
Long-haul Male 305,285.47 1,379 496,211.10 0 8,075,947 170,131.00
Female 255,720.16 1,771 284,627.14 0 4,762,258 203,901.00
Within Male 427,182.97 2,589 905,941.29 0 17,192,394 178,516.70
Female 360,333.00 2,165 882,086.77 0 20,327,593 173,667.00
176
3. Age group comparison
Younger patients spent less than older patients on both OP and IP services (Table
5.41). Patients from within-region spent more than those from long-haul regions in
all age groups.
Table 5.41: Medical expenditure of medical tourists between regions by age groups
Region Age group Mean N Std.
Deviation
Minimum Maximum Median
OP
expense
Long-haul Less than 25 6,941.75 2,824 15,534.46 0 276,457 2,740.00
25-34 11,966.52 4,220 28,413.33 0 876,611 4,032.50
35-44 20,191.48 5,397 55,641.67 0 3,186,743 7,398.35
45-54 25,537.44 6,177 56,532.11 0 1,861,343 11,160.00
55-64 27,189.68 5,438 47,787.08 0 1,299,511 11,716.00
More than 65 25,263.58 2,878 49,804.18 0 1,293,485 8,457.00
Within Less than 25 12,439.78 11,760 24,320.95 0 837,708 5,800.00
25-34 19,107.07 14,416 31,190.66 0 1,213,605 11,200.00
35-44 24,609.79 16,008 34,047.26 0 1,191,872 16,620.00
45-54 30,367.09 14,466 45,594.77 0 2,318,569 21,434.00
55-64 36,224.44 9,347 62,918.50 0 3,027,182 24,177.50
More than 65 39,641.96 5,748 57,392.62 0 1,076,213 25,248.50
IP expense Long-haul Less than 25 162,349.50 434 181,755.20 0 1,884,675 136,398.00
25-34 188,663.43 546 143,587.29 3,775 2,047,694 187,147.00
35-44 252,474.04 527 283,800.87 7,737 4,258,342 202,953.00
45-54 288,217.47 653 402,207.98 0 5,130,918 201,078.00
55-64 350,845.63 570 536,706.32 5,801 8,075,947 228,723.00
More than 65 425,797.22 421 544,559.11 20,831 4,045,855 269,062.00
Within Less than 25 246,993.98 595 567,556.07 0 7,352,828 110,614.00
25-34 222,178.31 647 390,172.60 0 6,228,379 150,964.00
35-44 220,008.46 760 289,052.17 5,667 3,475,997 146,609.50
45-54 373,625.74 875 768,717.57 0 9,365,116 178,635.00
55-64 462,984.98 872 989,243.86 608 16,735,084 211,411.50
More than 65 694,064.68 1,005 1,390,495.27 0 20,327,593 313,817.00
4. Statistical analysis
A two independent sample T-tests were employed to test whether there is any
difference in the average OP and IP expenditures of medical tourists from within-
region and long-haul regions. The null hypothesis was that there would be no
difference between the two groups. A considerable significant difference (p value <
177
0.0001) was found in both the OP and IP expenditures of medical tourists from
within-region and long-haul regions (Table 5.42).
Table 5.42: Comparison of medical expenditures of medical tourists, by regions
Means N 95% CI p value
Lower Upper
Total OP
expenditure
Within region 25,384.20 71,757 4,461.61 5,720.98 < 0.0001
Long-haul regions 20,692.99 26,939
Total IP
expenditure
Within region 396,739.09 4,754 93,492.39 161,492.76 < 0.0001
Long-haul regions 277,363.50 3,151
178
5.5 Discussion and conclusion
This section presents a summary of the research findings, a general discussion on
various aspects of the expenditure of medical tourists, a discussion on the limitations
of the data in the analysis, and a conclusion.
1. Summary of research findings
293 medical tourists participated in the survey. 68% of them were from within-region
while 32% were from long-haul regions. They were administrative/managerial
employers, agricultural workers and retired persons. Approximately 34% of them
were visiting Thailand exclusively for medical purpose, 50% of them had other
reasons for their visit, while 16% of them had subsequently added medical services
to their visit. Around 40% of them were new patients, while 40% of them had visited
Thailand for medical services on more than three previous occasions. Long-haul
patients tended to be first-timers, while patients from within-region were repeat
customers. Long-haul patients travelled with a medical service package, while
patients from within-region had usually organised their medical services themselves.
Long-haul patients tended to spend more time in Thailand than those from within-
region: approximately 12 and 8.9 days, respectively. Almost 50% of patients
travelled alone. Participants from within-region tended to have more companions
than those from long-haul regions.
Medical tourists and their companions spent more on tourism than non-medical
tourists: average tourism expenditure was 82,520 THB, 80,350 THB and 31,970
THB, respectively. Non-medical tourists from long-haul regions spent more on
tourism than those from within-region: 43,240 THB and 24,920 THB, respectively.
In contrast, medical tourists and companions from long-haul regions tended to spend
less on tourism than those from within-region. Average tourism expenditures of
medical tourists from long-haul and within-region were 64,280 THB and 90,950
THB respectively, while one of companions from long-haul and within region are
71,620 THB and 83,980 THB respectively. Male patients tend to spend more on
179
tourism than female patients. However, gender doesn’t affect the spending pattern of
non-medical tourists.
The profile of tourism spending, including the elements of local transport,
accommodation, food and drink, sight-seeing, shopping, entertainment and other
expenses were analysed. In terms of tourism spending per day of visit, medical
tourists and their companions spent more than non-medical tourists, the averages
being 8,440 THB and 4,190 THB, respectively. Companions of medical tourists
spent slightly more than the medical tourists themselves – an average of 9,080 THB.
Accommodation, food and drink and shopping were the categories accounting for the
most expenditure among all three groups. Non-medical tourists, medical tourists and
companions from within the region tended to spend more than those from long-haul
regions in all tourism categories except accommodation. Long-haul patients and their
companions spent more on accommodation. Male medical tourists spent more than
female in all tourism categories except accommodation. Similarly to overall tourism
expenditure, gender did not influence the tourism spending profiles of non-medical
tourists.
Many factors influence per-day tourism expenditure, including the fact of being a
medical tourist, gender, region of origin, age and income. Medical tourists, travellers
from long-haul regions, female travellers and higher income travellers tended to
spend more; however, the longer the stay, the lower the expenditure per day.
In terms of medical expenditure, medical tourists spent more than Thai private
patients on both out-patient and in-patient services. The average OP expenditure of
medical tourists and Thai private patients was 24,520 THB and 15,280 THB
respectively. The average IP expenditure of medical tourists and Thai private patients
was 353,460 THB and 120,880 THB, respectively. Male medical tourists and male
Thai patients spent more on IP services than the women in these categories. In
contrast, there was less difference in OP expenditure between medical tourists and
Thai patients. Due to disease complexity, the older patients were the higher their
expenditure on both OP and IP services. Medical tourists from within the region
spent more on OP and IP services than those from long-haul regions. Similarly to the
180
picture among medical tourists generally, gender influenced only IP expenditure.
Male patients from both long-haul and within-region areas spent more than female.
Though medical tourists tended to spend more than Thais, domestic patients still
generated more revenue in total: 13.7 billion THB in the five hospitals in the study;
while medical tourists generated 5.2 billion THB.
2. General discussion
This chapter demonstrates a distinct typology of the medical tourists in Thailand.
Information from the patient survey shows that medical tourists who obtained
medical services in Thailand differ in terms of the importance of medical care as
their reason for travelling. Some had travelled to Thailand exclusively for medical
services. This group would be called “mere patients” in Cohen’s classification [145].
Some of them were “mere tourists” at the start of their travel, but subsequently
added a healthcare element to their trip. Some fell between these two groups, having
travelled to Thailand for a variety of purposes, medical treatment being just one of
them. Findings from this study are supported by the study of Wongkit (2013) [146],
which reported that 40% of medical tourists were initially hesitant, making decisions
about medical treatment after arriving at their destination. This indicates a good
opportunity for health providers to attract “mere tourists”, a much larger group than
medical tourists, to participate in health activities.
An analysis in the patient survey demonstrates that a “medical tourist” is not only an
overseas patient seeking health services internationally, but also a real tourist. They
display the same tourism behaviours as an ordinary international tourist. Moreover,
they spend as much on tourism as on medical elements, an average of 82,520 THB
and 78,100 THB, respectively. Concordant with findings from the previous chapter,
40% visited hospital for health check-ups, which implies that they were more or less
healthy or have only non-complicated conditions. This implication is supported by
the findings of the patient survey showing half of these patients, although travelling
to obtain medical services, had other reasons for their visit besides medical care.
181
Approximately 40% of the medical tourists studied had been to Thailand for medical
care on more than three previous occasions. This reflects a reasonable level of
satisfaction with quality of services, together with competitive prices. A return visit
from customers, particularly those from within-region, confirms high quality and an
international standard of services. However, this information came from five leading
private hospitals, all of whom were certified by JCI. Furthermore, it was found that
patients from long-haul regions tended to be new customers. Long-haul patients
prefer to use medical service packages, which usually comprise a single visit for non-
complicated treatment, such as health check-ups or simple cosmetic surgery. Patients
from within-region are able to travel more easily and they tend to have organised
their trip themselves. They are also able to visit more frequently than those travelling
longer distances.
An analysis of tourism expenditure shows that medical tourists behave like ordinary
tourists, engaging in all tourism categories, particularly shopping and entertainment
which are comparatively unusual activities for people who are ill. Moreover, they
spend much more on tourism than non-medical tourists – approximately 2.6 times
more. They may be more affluent, being able to afford medical services abroad. The
study further found that half travelled with companions: an average of 2 companions
per patient. These companions also spend on both medical and tourism elements in
the same way as medical tourists, and this revenue adds substantially to the country’s
economy.
The study also found that non-medical tourists from long-haul regions spent more in
terms of total tourism expenditure than those from within the region, as they tend to
stay in Thailand for longer periods. However, an analysis of tourism spending
profiles demonstrates that tourists from within the region spend more on tourism per
day than those from long-haul regions. These findings would guide an alignment of
market segmentation for non-medical tourists. Thus, it is possible for tourism policy
maker to establish policies to increase the spending of tourists from long-haul
regions, and to lengthen the stay in Thailand of tourists from within the region, in
order to increase revenues.
182
The analysis of medical expenditure shows that medical tourists spend much more
than Thai patients – 1.6 times greater on OP and 3 times greater on IP services. This
is due to differences in types of disease, types of procedure and lengths of stay
between medical tourists and Thai private patients. In terms of total revenue,
however, Thai patients generate much more than medical tourists. Total revenues
generated by Thai private patients and medical tourists in the five hospitals in 2010
were 13.7 billion THB and 5.2 billion THB, accounting for 0.12% and 0.04% of
GDP respectively in 2010. The revenue from medical tourists of 5.2 billion THB is
much lower than all the estimates of previous studies. NaRanong et al (2011)
estimated medical revenue of around 46-52 billion THB [10]. The Ministry of Public
Health estimated revenue from international patients in 2007 at around 33 billion
THB, while Kasikorn Research Centre and the Ministry of Commerce estimated
around 36 and 41 billion THB respectively [143]. All estimates are considerably
greater than the real figure, since they were based on 1.5-2 million medical tourists.
This exaggerated estimate of the numbers of medical tourists has been the only
information available for academia and policy makers in Thailand, as described in
the previous chapter. This rather fantastic amount of revenue has encouraged
politicians and trade-related organisations to focus intensively on these overseas
patients.
As medical tourists are non-homogeneous, their expenditure depends on their
demography and the services they require. This study found that patients from within
the region spent more than those from long-haul regions. Findings presented in the
previous chapter show that patients from within the region tended to be visiting for
treatment for more serious conditions. They needed comprehensive medical care of
an acceptable quality which was not available in their country. Meanwhile patients
from long-haul regions came for services which were either not covered by their
national health insurance, or were too expensive to access in their home country.
Male patients spent more than female, and older patients spent more than younger
ones. In terms of gender and age, male patients and the elderly tended to have more
complex conditions than female and younger patients. These findings will allow
hospitals marketing to specific groups of patients to enhance their revenues.
183
3. Conclusion
This chapter demonstrates how much revenue medical tourists generate for the Thai
economy, by exploring their spending on both medical and tourism elements. The
literature review uncovered very little literature presenting empirical evidence of
these tourists’ expenditure, even on its medical component. This chapter suggests
that medical tourists behave as both patient and tourist. They spend much more on
medical expenses per person than local Thais. They and their companions also spend
much more on tourism than non-medical tourists: 82,520 THB per patient, and
80,350 THB per companion. Yet this study also found that there were fewer medical
tourists than previously estimated. Several recommendations for policy makers are
outlined below.
Market segmentation
As medical tourists are non-homogeneous, representing different health needs
depending on where they are from, policy makers should be more specific in their
marketing strategies. Greater market segmentation will allow more targeted
recruitment, focused on those medical tourists with the most potential to add value to
the Thai economy.
Based on the results presented here, specific areas or patient groups are identified as
areas of potential policy focus:
o Medical tourists are particularly lucrative tourists. While their expenditure on
medical treatment is in some cases low, their real contribution is to the Thai
economy through the revenue from their tourism activities, which is
disproportionately higher than that of non-medical tourists. This overall
finding means that focus should be on how to recruit tourists through a
‘medical element’, how to maximise their tourism expenditure, and ensure
that any potential negative effects for the health system will be offset.
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o Patients from within the region, in particularly those from the Middle East,
are particularly lucrative.
o Services targeting male and older patients should be established to increase
hospital revenues.
The number of non-medical tourists travelling to Thailand is much greater than
the number of medical tourists. However, results from this study suggest that
some tourists decide on and engage in ‘minor medical treatment’ when they are
already in Thailand. Therefore, to increase national revenue it would be worth
targeting promoting medical services to tourists in Thailand. These tourists
represent perhaps the largest and most easily accessible medical tourism market
for Thailand.
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Chapter Six
Impact of medical tourists on private hospitals
and domestic private patients
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Chapter 6 The impact of medical tourists on private hospitals and
domestic private patients
The flourishing phenomenon of medical tourism has challenged the policy makers
responsible for promoting Thai health services to other countries. They need to look
at the impact this phenomenon may have on domestic resource utilisation and service
provision for domestic patients. An increase of incoming medical tourists results in
an increased demand for healthcare, in particular of patients looking for highly
specialized care. This phenomenon is underpinned by an expansion of the middle
classes in many developing countries, who can now afford services abroad [66]; and
an increase in patients who are uninsured and uncovered in some specific (especially
high-end) services by their national health insurance [6, 67].
The increased demand for healthcare arising from medical tourism may be met by
four distinct routes: (i) utilising resources that would otherwise have been used to
treat domestic public patients [147]; (ii) utilising resources that would otherwise have
been used by domestic private patients; (iii) utilising spare capacity (in public or
private sector); and/or (iv) specific foreign-built and operated facilities. Each has
very different implications for the domestic health system and the domestic
population. Utilizing a hospital’s spare capacity would have a limited effect on
domestic supply, while importation of resources, especially human resources for
health, would similarly generate little effect on domestic supply although it might
have a deleterious impact on source countries. Rather, from a receiving country
perspective, it is especially important to consider whether additional resources used
by medical tourists are transferred from the domestic public or private sector, and
hence whether medical tourists displace care for domestic patients. It is therefore
important to understand the mechanisms for the internal allocation of resources
between foreign and local private patients.
This chapter aims to analyse the impact of medical tourists on the domestic health
system, specifically private hospitals and domestic private patients. The key concern
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is whether medical tourists displace domestic patients, both in the sense of competing
for significant resources, and whether the benefits derived from the use of these
resources return appropriately to the domestic health system. The first issue is
therefore how resources required for medical tourists are obtained; spare capacity,
allocation from private resources, domestic recruitment from public sources and
importation from international sources. Although this covers all resources used for
providing services, including buildings, beds, medical equipment, drugs, etc., human
resources are of special concern, as they are almost entirely publicly produced and
their utilisation for the treatment of medical tourists might be expected to have a
significant impact on the treatment of public patients.
The second issue concerns where the revenues generated from medical tourists are
allocated. They could be allocated to cover only the cost of care, subsidise care for
local patients, be reinvested in the expansion of service capacity, be returned in some
way to public services, paid as corporation tax for government revenue, or as income
for shareholders. Understanding the allocation of revenue would assist in further
understanding who gains from medical tourism.
The last issue is whether there is inequity in treatment between nationals and
foreigners. Inequity might vary from offering a different treatment guideline,
considered as a critical issue, to more minor differences, such as providing special
food for medical tourists while they are hospitalised. Some differences will be
appropriate, such as provision of translators, but others, it could be argued, generate
either better or worse care: for example extensiveness of diagnostic tests, sufficient
in-patient stay, or follow-up care.
Findings from all these issues are analysed in this chapter to generate an
understanding of whether medical tourists are likely to have a beneficial or
detrimental effect on the domestic health system, specifically the private sector, and
establish who may stand to gain or lose from medical tourism.
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6.1 Aim and specific research questions
The aim of this chapter is to assess the impact of medical tourists versus domestic
private patients on private hospitals. The specific research questions are:
1. Are medical tourists treated differently from domestic private patients –and if so
why?
2. How are the resources required for medical tourists obtained?
3. How are the revenues from medical tourists allocated?
Results
Interviews with 15 hospital executives, 12 doctors and 16 nurses in Bumrungrad
International Hospital, Bangkok Hospital, Bangkok Pattaya Hospital and Bangkok
Phuket Hospital were conducted between May-August 2012. Information from the
interviews were analysed with a framework approach analysis, and the results are
presented here.
6.2 Difference in service use between international and Thai patients
6.2.1 Service provision between domestic and foreign patients
There is no difference in critical aspects of care, such as medical treatment guidelines
and choice of drugs, between foreign and local patients, but there are some
differences in peripheral areas to enable care due to the “tourism” elements, such as
translator and transfer services. However, this difference does not translate to a
quality of care difference. Furthermore, foreign patients have to pay extra to cover
these additional services.
All four hospitals have international service standards accredited by JCI. Standard
practice guidelines of treatment are applied to all patients regardless of their status.
All physicians and nurses participating in this study unanimously agreed that all
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patients are treated within the standard medical guidelines. All guidelines are
established by Thai specialist associations and they are also benchmarked against
international standards.
“We have the same guidelines for both groups (Thai and international
patients). As the customer is our main business, we have to provide a uniform
standard of service” (H4E3)
“There is no difference. We apply the same guidelines to all patients. We just
have to inform their diagnosis and treatment plan” (H4M2)
“I’ve worked here for 13 years. I don’t think to provide different services
between Thai and overseas patients. We treat them with the same standards”
(H1N1)
Though most diseases have a single treatment of choice, some have more than one.
Furthermore, some operations have many operating approaches, such as exploratory
laparotomy or endoscopic approaches, which have different resource requirements
and hence a different price. In these cases, all available choices are explained to
patients for their consideration. Treatments are chosen by patients regarding their
ability to pay. This approach is employed in the case of both Thai and international
patients.
“We explain all available options of treatment to patients. Then patients have
to choose depending on their budget. We also apply this approach to Thai
patients” (H4M2)
“Before starting a treatment, doctors will explain all the drug options to
patients. Regarding their budget, patients and their relatives will choose the
most appropriate option for them” (H3N1)
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Despite the same standard guideline, in terms of time allocation, international
patients tend to need more time from hospital staff compared with Thai patients. The
first reason is due to language difference, which necessitates more time for
communication. Most Thai physicians have comparatively good English, but there
are often language issues associated with nursing and other staff. It is also much
more time consuming to communicate with non-English speaking foreign patients.
Thus all hospitals have translators to facilitate communication. The second reason is
that international patients tend to be given a more in-depth consultation. Western
culture and higher education often seems to increase the demand for physicians and
nurses to provide more information on their disease and treatment plan to overseas
patients [10]. Some overseas patients sought second opinions from their home
country where they were treated before, or from other countries, before visiting Thai
hospitals. They therefore came with some experience of treatment and some
information about their problems.
“It’s no problem if patients can speak English. However, if they need
translators, it would take more time” (H2M1)
“This is a difficulty. Due to a different language, we talked through
translators. It took 2-3 times the usual time” (H3M2)
“Medical tourists spent much more time with doctors. We have to accept this
as they travelled in order to receive information and services. Then they will
talk with our doctors for a long time” (H2H1)
In terms of medical services, overseas patients and Thai patients are entitled to be
provided with the same services. In actuality, they obtained the same standards of
clinical practice guidelines, the same treatment, the same operations and the same
choice of drugs. However, they needed a different allocation of a physician’s time.
Overseas patients needed more time for consultation and communication than Thai
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patients. However, there is no evidence that spending a longer time with patients had
any effect on quality of care or health outcomes compared to Thais.
Apart from direct medical services, there are some differences in the peripheral
services provided to Thai and international patients. Overseas patients obtain some
privileges from private hospitals, such as special transfer services and special food.
These extra services aim to facilitate and to accommodate the patients’ cultures
during their stay in a Thai hospital. These services are described below.
Translator
Many overseas patients are from non-English speaking countries. To mitigate
difficulty in communication, all hospitals have translators. Most are recruited from a
variety of nationals who also speak English. Translators have an important role in
facilitating communication between patients and hospital staff. Moreover, native
translators often make patients feel more at ease and comfortable in an unfamiliar
environment. Some hospitals have more than 100 translators covering more than 10
different languages. However, with the growing level of overseas customers, some
hospitals felt that this number was still inadequate. A limited number of translators
cannot meet all patients’ needs at the same time. Sometimes, medical consultation
and medical treatment was delayed as there was no translator available: doctors and
patients had to wait. In these cases, a tele-translator might be used. The hospital
translator centre provided a pool of translators as a 24-hour service; doctors and
patients could communicate with these translators via video-camera in real time. This
reduced the need for a translator to be actually present during treatment. However,
some patients still preferred an actual translator to be present rather than talking to
them via video-camera.
“We have over 100 interpreters and about 10 different languages and the
numbers are proportionate to the number of specific groups like the single
biggest groups is Arabic because we have a lot of patients speak Arabic, we
also have many Burmese and Cambodian, Vietnamese and Chinese
interpreter” (H1E2)
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“If we have more understanding in their culture, they feel more comfort to
come. In Arabic patients, when they see our staff being like them, speaking
the same language with them. They feel like their friends. Then, they prefer to
come” (H3E4)
Transfer services
Bangkok Pattaya and Bangkok Phuket hospitals provided a special service to transfer
overseas patients from airport and hotel to hospital. Most medical tourists had
advance hospital appointments. Hospitals arranged transfer services if patients
requested them, but the service was not offered to expatriates or Thai patients.
“We have transfer service for medical tourists from airport or hotel to our
hospital. This is a free service ………. this is a value added to our service.
We serve them from hotel to hospital every day until they finish their
treatment” (H4M2)
Special food
All hospitals provided special food menus to accommodate patients’ cultures: for
example, Islamic food or Myanmar food, etc.
“We serve different menu of food. We feel uncomfortable when we are in an
unfamiliar environment. We would like to ease our patients” (H2E1)
Some differences in services, particularly the provision of a special translator,
sometimes created unfavourable perceptions in Thai patients. Clinicians reported that
some Thai patients thought that overseas patients received more privileges, as
hospitals provided special staff to escort foreigners. They also felt that physicians
and nurses spent more time on foreigners.
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“Sometimes, it looks like we serve foreigners with better services. Having
translator looks like we provide them a personal escort. Actually, we equally
serve both Thai and international patients but we can communicate easily
with Thais” (H4E2)
“Some Thai patients thought that we take more care on international patients.
We have some difficulties in communication. It took time for understanding
while we can easily communication” (H3N4)
In summary, it was apparent that overseas and Thai patients were receiving the same
clinical practice guidelines of treatment. They received the same drugs, the same
investigations and the same operations. In the case of more options in treatment,
customers were given information to allow them to choose the best option,
depending on their ability to pay, regardless of whether they were foreigners or not.
Overseas patients, particularly from non-English speaking countries, tended to spend
more time with the physician. Moreover, some special services were provided for
overseas patients, such as translators, insurance coordinators and transfer services.
6.2.2 Price There were two types of pricing policy in the four hospitals – the same price for all,
and different prices for Thai patients and medical tourists. Those hospitals employing
the same pricing policy for all patients, regardless of their being Thais or foreigners,
charged all patients the same price. However, in order for this to be the case, the
costs occasioned by services specifically for international patients, such as
translators, international insurance coordinators, e-business offices and others, were
distributed across all patients, meaning that domestic patients had to subsidise
foreign patients.
“We don’t discriminate among patients. Discrimination includes pricing
system. We have the same price between Thai and overseas patients” (H1E1)
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Alternatively, in hospitals using different pricing systems for foreign versus domestic
patients, international patients paid more than Thai patients, as they were charged
directly for the cost of the additional services they needed specifically because they
were foreign. Thus, in these hospitals, there is no such subsidisation for foreign
patients.
“To do foreign affair, we need to have special team. Most are foreigners.
They are also translators…………….This results in additional cost. Second,
we have additional cost arising from coordinating with international
insurance regarding time different between regions. We have to add this
additional cost to overseas expense” (H4E2)
All hospitals provided a service package with a single price for both Thai and
overseas patients. This was a set of services including preliminary investigation
(blood check, urinary check, x-rays and others), operations, drugs and follow-up
service. A service package was always provided in elective procedures, such as
dental and cosmetic procedures. Patients paid once and received all included
services. This helped patients to estimate their expenses and reassured them that they
would not have to pay any other additional charges. The service package was the
same price for all patients – Thai and international.
“International patients use the same package as Thais. In the past, we used to
add in some items for foreigner price. Currently, we don’t add as they would
complain” (H2M1)
“We told international patients about this package. They can come for follow-
up without any additional expense” (H2N1)
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6.2.3 Resource allocation
Chapter 5 shows that revenue from international patients was much higher than from
Thais per capita. However, in terms of numbers of patients, Thai customers were a
majority in all hospitals. Hospital executives consistently stated there was no
discrimination in catering for their patients whether they are foreigners or Thais.
“Our policy is no difference. We follow through our quality assurance system
in catering all types of patient regardless being foreigner or not” (H4E1)
“We cannot discriminate between Thais and foreigners. It’s not at all. If we
do that, we will lose our focus in our business. We have to see them as a
patient. Each patient is the heart of our business” (H2E2)
Hospitals did not try to separate overseas customers into special departments.
However, in practice some hospitals did have special separate units for foreigners for
several reasons. Bumrungrad hospital and Bangkok hospital had a substantial number
of patients from the Middle East and Japan. There was a separate special registration
unit for them, in order to facilitate efficient management of translators. After
registration, Middle Eastern and Japanese patients in Bumrungrad hospital had to
visit a pool of physicians in the out-patient department, while Bangkok Hospital
provided a special out-patient unit for internal medicine for both groups. They
allocated physicians and nurses specifically to treat them in this department. Apart
from effective resource management, another reason for a separate department was to
accommodate patients’ cultures. Patients from the Middle East preferred to live like a
community, arriving with many companions, so hospitals arranged a separate area for
them. However, there was no separate ward for other international patients in these
two hospitals.
“We try to separate special area for Middle East. We have one in out-patient
unit in 10th floor. We separate between Thai and international customers in
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order to facilitate a management of translators. However, we don’t separate in
in-patient department” (H1E1)
“We have separate building for international patients. There are three unit for
Arabic, Japanese and international patients………….Patients are screened
there. If they need to see doctor, they will be sent to another building. It looks
like they have to have a first visit there” (H2N2)
For in-patient service, there were difficulties in allocating a specific ward to
international patients. The small number of patients and the variety of their diseases
made it too inefficient to manage.
“In the past, we used to separate international patients into the same ward.
However, currently we don’t do this as we met a lot of problems. We had
variety of diseases so we cannot manage effectively. Nowadays, we separate
wards depending on specific diseases instead” (H3E1)
In other departments serving both Thais and foreigners at the same time, all patients
were allocated a physician specifically for their problem, regardless of nationality.
First come first served was employed for both groups. This approach was also used
for prioritising appointments with doctors for elective procedures, such as dental and
cosmetic procedures. However, most medical tourists had planned their treatment for
a long time. They usually made an appointment with doctors 2-6 months in advance.
These advance appointments resulted in a nearly-fully occupied schedule in
particularly popular slots where there were only a small number of specialists. Some
doctors had a tight schedule for a year ahead. This might cause problems for walk-in
Thai patients in accessing these specialists. For hospitalization, severity of disease
and urgency of condition were the first priority: these were judged by physicians at
out-patient and emergency departments.
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“We do not save or in favor for any group of patients. Just kind of first come
first serve and the Thai patients are here in the country so they usually have
easier access to make sure that they can get into the hospitals” (H1E2)
“It’s a first come first serve. We reserve for patients who book in advance.
Most of them are medical tourists. They usually book 2-3 months in advance.
Some cases may be 6 months” (H4M2)
“Our capacity doesn’t reach 100%. We don’t have any favour for overseas
patients. We admitted them as their condition at that moment. We still have
spare capacity” (H4E1)
In summary, in terms of hospital policy, there was no discrimination in managing
patients regardless of whether they were foreigners or Thais; foreign patients
received the same critical aspects of medical care. In practice, however, they tended
to take more time from doctors and nurses. Furthermore, they were provided with
particular services relevant to the tourism element of their visit, for which they
usually had to pay extra. These kinds of difference did not mean discrimination in
quality of care compared to that given to Thais. However, long-term planning for
treatment could limit the ability of Thai patients to access some specialists.
6.3 Resources for international patients
6.3.1 Infrastructures and medical devices An increase of customers and new medical technology were key contributing factors
to the need for expansion of capacity in all the hospitals in the study. Some increased
capacities were designed to serve both Thai and foreign patients; there was
investment in new buildings to cater for increased demand from both. Bumrungrad
Hospital had invested in their new in-patient building as they had encountered
limited bed capacity due to a low bed-turnover rate; patients sometimes had to wait
for a bed to become available.
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“Recently, we have 2,900-3,000 patients per day in out-patient department.
We have very limited bed for new patients as we cannot rotate our old
patients. Nowadays, our hospital looks like a university hospital. We have
many patients waiting for their beds” (H1E1)
“Yes, we built the building, we added bed and we are building extra capacity
now. This entire floor; 12 floor will convert to inpatients bed” (H1E2)
In contrast, Bangkok, Bangkok Pattaya and Bangkok Phuket hospital still had spare
bed capacity. One reason was that they were in the same company – Bangkok Dusit
Medical Services Public Company Limited (BDMS), which had a policy on resource
sharing for efficient utilisation. Some patients were sent for post-operative care and
palliative care to other hospitals outside Bangkok.
“We have around 70% of bed occupancy rate. In our peak period, all our beds
are occupied but it lasts for a few days. An average is 70%” (H3E1)
“We have special signal. The first level is when we have 80% of bed
occupancy rate. The second level is 90%. The third level is all our space is
occupied. We have to send patients to our network hospitals” (H2E2)
Some capacities have been expanded focusing only on overseas customers; for
example, Bangkok Phuket hospital had been promoted as an aesthetic hub in the
southern region of Thailand. Several years previously, a large number of medical
tourists, particularly from Australia, began to visit this hospital for cosmetic surgery.
The hospital used the revenue from this to build a new floor just for aesthetic
services, focusing on serving medical tourists.
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“Aesthetic and dental clinic are profitable unit for us. They create lots of revenue. We
set up special floor for aesthetic clinic” (H4E3)
Furthermore, most hospitals aim to be a medical centre of excellence. It was
therefore vital for them to keep up with new medical technology at the global level.
For this reason, they invested in new, advanced medical equipment; some considered
it a good opportunity for Thais to gain access to this world-class technology.
However, some sophisticated devices tended to be used specifically for overseas
customers: Bangkok Phuket invested in a device for endoscopic breast augmentation,
a popular technique for overseas patients, but not available for Thais.
“Our main aim doesn’t specify on Thai. It focuses on medical technology and
medical education. We had this technology for 4-5 year while no one else
had. Currently, everyone have this so we have to seek the better one” (H2E1)
In summary, all hospitals had continuously expanded their capacity to cater for a
growth in numbers of patients. Some capacities aimed to serve both Thai and
overseas customers, while some extra capacity was targeted only at foreigners. Much
advanced medical equipment was imported to increase service capability towards
world-class technology. All expansions of capacity were funded by domestic
investment from revenues from hospital operation.
6.3.2 Human resources for health
The health system is labour intensive. At the heart of every health system, the health
workforce is central [148]. It is one of the most finite resources. Health system
performance depends on the knowledge, skill and motivation of the people
responsible for delivery of services. This limited resource has been of the most
concern when considering the increased number of international patients using the
Thai health system.
Appropriate staff numbers and mix to meet patient demand are important issues for
private hospitals to ensure quality of service and patient satisfaction. Effective human
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resource planning is required. In essence, numbers of staff depend on numbers of
patients, regardless of whether they are Thai or foreign. However, particular staff
needed when treating foreign patients, such as translators and international insurance
coordinators, are directly determined by numbers of international customers.
“In principle, we plan on overall patients, not being Thai or international in
origin. In each unit considered how much their patients increased and then plan
for how much staffs they required” (H4E4)
“We have our staffs that are not Thai. We have unit for management on
international affair. We have foreigners to be our translators” (H3E4)
Serving international patients drives all hospitals to seek more qualified staff.
Proficiency in English is a crucial qualification in the recruitment of new staff. Most
Thai doctors have some problems, and most new graduate nurses have considerable
difficulties, with English. Furthermore, hospitals require more staff to have bachelor-
degrees to ensure at least a basic level of English. Many lower-skilled hospital staffs,
such as ambulance drivers and concierges, have bachelor degrees. Higher
qualification standards make it more difficult for hospitals to recruit personnel.
“We have a problem in recruiting new staffs as we need more qualifications”
(H2E4)
“We recruited more bachelor degree staffs. We have bachelor-degree porters
and drivers. We trained them for appropriate move for patient” (H3E4)
“Not only international patients but also more advanced medical equipment
makes us need more qualified staff. Our business is based on IT that needs
higher skill” (H3E4)
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Sources of human resources for health
o Domestic sources
Private hospitals require newly qualified staff every year. Table 6.1 and Table 6.2
show the number of physicians and nurses in the Bangkok Dusit Medical Services
Company (BDMS). Bangkok, Bangkok Pattaya and Bangkok Phuket are part of this
company, which includes 28 private hospitals in all parts of Thailand. The number of
physicians and nurses in these hospitals has increased every year. The majority of
hospital staffs, particularly physicians, are recruited from domestic sources. In 2012,
there were 16 public medical schools and one private medical school in the country,
producing around 2,500 new graduates and 2,000 specialists annually. All the
specialists and more than 90% of new graduates are products of public medical
schools. Government subsidizes the training costs of new doctors and specialists, and
medical students pay very little for tuition fees. World-class private hospitals require
high-calibre physicians who have practised in public hospitals for at least 10 years to
gain the experience necessary to work in these hospitals.
An internal “brain drain” of health professionals, particularly of doctors, from public
to private hospitals has been a problem for the Thai health system for a long time
[39]. It creates an inequitable distribution of doctors between rural areas and
Bangkok. In 2008, the difference of population per doctor ratio between Bangkok
and the Northeast of the country, considered the poorest region, was around 5-fold;
the population per doctor ratio in Bangkok and the Northeast is 955 and 5,028
respectively [17]. Private hospitals play a key role in large cities, particularly
Bangkok. In 2008, 46% of bed capacity in Bangkok was in private hospitals and 32%
of doctors in Bangkok work in private hospitals [17]. Recently, between 500-700
doctors resigned from hospitals in the Ministry of Public Health in a single year [17].
Most of them moved towards specialty training and went on to work in private
hospitals. Though this problem is specifically at a public-private level, to some
extent it is caused by the increase in demand from international patients.
Private hospitals also have part-time doctors who work for less than 40 hours a week.
These doctors represent approximately 60-70% of the total doctors working in
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hospitals (Table 6.1). Most of them also work in public hospitals, particularly
medical schools: dual practice is allowed in Thailand and it is popular with
physicians working in medical schools and tertiary hospitals in Bangkok and big
cities. They work in private hospitals after 5 P.M. and over the weekend. They
sometimes receive telephone-consultations from private cases during office-hours.
There are fewer part-time nurses compared to doctors (Table 6.2).
Table 6.1: Number of physicians in BDMS
2009 2010 2011
Full-time 303 321 345
Part-time 499 518 612
Total 802 839 957
Source: BDMS Annual report
Table 6.2: Number of nurses in BDMS
2009 2010 2011
Full‐time 594 589 787
Part‐time 20 26 145
Total 614 615 932
Source: BDMS Annual report
To recruit new doctors, hospitals use both advertising through the media and personal
invitation to doctors at other hospitals. To obtain new nurses, some hospitals recruit
directly from the numbers of newly graduated nurses from universities and nursing
schools.
“We used many approaches. For domestic trained specialists, we used personal
invitation. We sound out doctors in medical schools” (H3E2)
“We have to recruit new nurses from all over the country” (H3N4)
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o Importation
Some hospital staffs are recruited from international sources. Some Thai doctors in
Bumrungrad and Bangkok hospital used to work abroad, and some of these moved
back because they wanted to work at home.
“Many of our Thai doctors, for example, already work in US and they came
back. It is kind of reverse brain drain, because they can come back and work
here it is very advance hospital setting so we do not have brain drain problem
and we do not see AEC as a threat” (H1E2)
“10% of our doctors have American-board and used to practice there. Next
week, we will have one from Baltimore” (H2E2)
“For abroad trained doctors, we advertised in our website. They contacted us
and we had an interview. If they match with our hospital, we accept them”
(H3E2)
There are some foreign doctors and nurses working in Bumrungrad and Bangkok
hospital; however, they do not practice clinically. Regarding the regulations of the
Thai Medical Council and Thai Nurse Council, all doctors and nurses who practise in
Thailand have to pass a licensing examination in the Thai language. Not all of them
have enough Thai proficiency to pass the examination, so they work as medical
coordinators and nurse coordinators. These staffs help overseas patients set up
appointment and treatment plans. They facilitate case management and coordination
for international patients.
“We also have other groups of doctors and nurses about 40-50, we call medical
coordination and that includes international nurse from Australia and Arabic
doctors in that team, Japanese doctor, Mongolian doctors and Vietnamese
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doctor. They do not do practice clinical, they do case management and case
coordination” (H1E2)
“So if you are international patients come for check-up you might not need to
check up, you easily to do it yourself, but if you come for spine surgery or
heart surgery. You need help setting up your appointment and treatment plan.
We can’t assume you are going to be in Thailand for 6 months. You might
come in just a few days and get everything in that period of time so you need
coordination and that is very efficient” (H1E2)
“We have foreigner staffs but they cannot pass Thai license. We hire them as
physician coordinator and nurse coordinator. They help us a lot” (H2E4)
In summary, human resources for health are a very important part of hospital
business. The public sector plays a key role in production: the main source of health
personnel in private hospitals is from public hospitals. Highly skilled physicians are
recruited directly from medical schools and tertiary hospitals; very few are recruited
from western countries.
6.4 Revenue allocation
Thai patients predominate among patients in all hospitals except Bumrungrad
Hospital, where the number of Thais is only slightly higher than that of foreigners:
around 55% and 45% respectively. In terms of revenue, Bumrungrad Hospital gains
more revenue from foreigners than Thais. Figure 6.1 shows that revenues from
international patients in Bumrungrad hospital increased from 54% in 2008 to 61% in
2012. In contrast, private hospitals who are part of Bangkok Dusit Medical Services
Company receive more revenue from Thai patients than from overseas patients
(Figure 6.2).
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Figure 6.1: Revenue contribution by nationality in Bumrungrad hospital
Source: Bumrungrad Hospital annual Report [149]
Figure 6.2: Revenue contribution by nationality in Bangkok Dusit Medical Service
Source: BDMS annual Report [150]
An analysis of total medical expenditure in Chapter 5 shows that on average medical
tourist expenditure is higher than Thai: medical tourists spend more when they are
hospitalized. Furthermore, some hospitals have a different pricing system and
medical tourists pay more to receive extra services. Information from interviews with
hospital executives substantiates this finding.
“We have 70% of Thai patients and 30% of international patients. However, in
term of revenue, 55% is from internationals patients while only 45% is from
54 55 57 59 61
46 45 43 41 39
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2008 2009 2010 2011 2012
TH
Inter
36 36 3626 28
64 64 6474 72
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2008 2009 2010 2011 2012
TH
Inter
206
Thais. Thus international customers are very important for us but we don’t
forget Thais” (H4E1)
“Currently, we got revenue from overseas patients around 40% and from Thais
around 60%. International market has grown a lot. Though, majority of our
customers are Thai, they don’t expand as much as international group” (H2E3)
Disease patterns of international patients also differ from those of Thais, especially
for those needing hospitalization. Some come with more serious conditions, such as
cancer or orthopaedic problems, requiring operations and hospitalization. Thai
patients usually present with less serious symptoms and less complicated conditions.
Hence, average expenditure per patient for foreign patients is much greater than that
for Thais.
“Expenditure from overseas patients is greater than Thai. They came with
serious condition while they came with simple disease, just common cold”
(H2E4)
“We don’t charge them (Medical tourists) more than Thai. It is because of their
severity of diseases. Medical tourist obtaining cosmetic surgery didn’t pay less
than 100,000 THB per patients. We didn’t charge them a lot but there were
many procedures” (H4E2)
In Bumrungrad hospital, revenue from hospital operations in 2011 was 11,015
million THB (Table 6.3) while in BDMS it was 35,224 million THB (Table 6.4). As
mentioned above, this revenue is generated from both Thai and overseas customers.
Approximately 60% of revenue is spent on hospital operations, including labour
costs of physicians, nurses and other hospital staff, medical supplies and laboratory
tests. 12-14% of this is spent on shareholder benefits. 5% of revenue is sent to
government as corporate tax.
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Table 6.3: Revenue and expenditure of Bumrungrad Hospital
2009 2010 2011
million THB % million THB % million THB %
Income Revenue 9,068 9,794 11,015
Expenditure Operating cost 5,553 61.24 5,912 60.36 6,598 59.90
Administrative cost 1,415 15.60 1,678 17.13 1,858 16.87
Shareholder 1,245 13.73 1,258 12.84 1,588 14.42
Corporate tax 444 4.90 507 5.18 506 4.59
Source: Bumrungrad Hospital annual Report
Table 6.4: Revenue and expenditure of Bangkok Dusit Medical Services (BDMS)
2009 2010 2011
million THB % million THB % million THB %
Income Revenue 21,596 23,512 35,224
Expenditure Operating cost 12,593 58.31 15,350 65.29 23,675 67.21
Administrative cost 4,275 19.80 5,356 22.78 7,224 20.51
Shareholder 1,725 7.99 2,295 9.76 4,385 12.45
Corporate tax 546 2.53 779 3.31 1,456 4.13
Source: BDMS annual Report
Total revenue generated from overseas patients is between 30-60%. Main expenses
are operational costs, accounting for 60%. Revenue taken by government as
corporate tax is approximately 5%. Essentially, revenues generated from Thais and
foreigners are accumulated as revenues from hospital operations. It is relatively
difficult to separate the specific element generated by serving foreigners;
consequently, it is also difficult to identify exactly who benefits from these patients.
Regarding information on proxy revenue allocation, the Thai government receives
very little benefit directly from services to foreigners via corporate tax.
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6.5 Discussion and conclusion
This section presents a summary of research findings, a general discussion on the
impact of medical tourists on private hospitals and domestic private patients from
various aspects, a discussion on the limitations of data and analysis, and a
conclusion.
1. Summary of research findings
International and Thai patients were subject to the same clinical practice guidelines.
They received the same choice of drugs, the same investigations and the same
operations. International patients, particularly from non-English speaking countries,
tended to spend more time with physicians. Some special services were provided for
international patients, such as translators, insurance coordinators and transfer
services. All hospitals asserted that there was no discrimination in the management of
patients, whether international or Thai. However, in practice, there were some
differences, for example a special registration area for international patients.
However, these differences did not seem to affect the quality of treatment.
All hospitals, except Bumrungrad hospital, had a reserve bed-capacity to cope with
any extra demand of patients. However, it seems that all the hospitals had
continuously expanded their capacity, in order to cater for the growth of patients.
Some capacities were expanded in order to serve both Thai and international
customers, while some capacities were targeted specifically at foreigners. The
majority of hospital staffs were recruited from domestic sources. Highly skilled
physicians were recruited directly from medical schools and tertiary hospitals. Some
Thai doctors had previously worked abroad. Some international doctors and nurses
were working as medical and nurse coordinators.
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2. General discussion
There was no difference in critical aspects of care between international and Thai
patients. They were treated within the same medical guidelines and offered the same
procedures and choice of drugs. Additionally, however, in practice, international
patients were offered peripheral services relating to the tourism component of their
visit. Furthermore, they tended to need more time with doctors and nurses. One
reason was the language difference; some patients needed a translator so that both
parties could communicate in English; another reason for this was that international
patients tended to ask more questions and tended to want a more interactive
consultation. This finding supports the study of Na Ranong (2011) [10]. However,
these differences did not lead to differences in quality of care.
A different pricing system in the four hospitals has many implications. The single
pricing system ensures that all patients pay the same price. International patients
prefer to know that they are not being charged more for being foreigners; however,
Thai patients do not want to have to pay the same rate as international patients.
Moreover, under this system, Thais have to subsidise the extra cost of services
arising from the needs of international patients. However, price is not an issue for
Thai customers in this world-class hospital. A different pricing system would
generate other effects. This system creates inequity in price in a hospital.
International patients may misunderstand why they are being charged more, while
Thai patients would be more comfortable paying the Thai price. It is important in this
system that international patients are seen to pay more in order to cover the cost of
extra services, rather than for better treatment. According to the findings from
Chapter 5, medical tourists spend more on medical services than Thais, particularly
for hospitalization. The difference in services required for more serious conditions is
one of the contributing factors to this, as is the hospital dual-pricing policy.
First-come, first-served was an approach employed in all hospitals to ensure equal
access to services for all patients. This could be a problem in some fields of
medicine, with scarce specialists in high demand from international patients, such as
those providing dental and cosmetic treatment. International patients, particularly
210
medical tourists, usually plan their treatment at least 3-6 months in advance, while
Thai patients usually make walk-in visits. Lots of advance appointments might
displace access to services for Thais.
During the 1997 economic crisis, private hospitals had a lot of spare capacity, leading
them to market themselves to new customers from overseas. However, after
economic recovery, domestic demand increased, resulting in an increase in numbers
of Thai patients in private hospitals. At the same time, the reputation of Thailand as a
medical service destination has resulted in an influx of medical tourists; although as
indicated earlier, to nowhere near the extent commonly assumed. A growth of both
domestic and overseas customers has driven private hospitals to expand their
capacity to serve this demand. At the time of study, Bumrungrad hospital had very
limited reserve bed-capacity, as they operated as a single comprehensive hospital,
while the other hospitals operated as a group and had some reserve bed-capacity,
because they could transfer patients between hospitals within the group. Data from
the MOPH supports the view that private hospitals have plenty of spare bed-capacity
compared to public hospitals. In 2008, the bed-occupancy rate in private hospitals
was 60% whereas the bed-occupancy rate in public hospitals under MOPH was 83%.
This information substantiates the view that Thai private hospitals have capacity to
serve more patients.
An influx of medical tourists in Thailand would therefore be unlikely to crowd out
Thai private patients. Apart from plenty of spare capacity in private hospitals, the
number of medical tourists is substantial smaller than the number of domestic private
patients. Data from a private hospital survey by the Thai National Statistical Office
demonstrated that there were approximately 46 million visits in all private hospitals
in 2011 [30]. MOPH reported that there were approximately 136 million visits to all
public hospitals in the same year [31]. Thus, it would be difficult for medical tourists
to ‘distort’ the domestic private health system.
It is apparent that all hospitals obtain their resources, particularly human resources,
from domestic sources. Most doctors are recruited from the public sector. Some part-
time doctors are still working in medical schools and tertiary public hospitals.
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However, there is a reverse brain drain of doctors from abroad, albeit a minor one.
An internal brain drain of health personnel moving from public to private hospitals
still remains. However, it is difficult to claim that this is because of a growth of
medical tourists, as all providers still serve Thai patients who constitute the vast
majority of patients.
An interesting finding which arose from interviews was that hospitals had a new
strategy to mitigate the shortage of doctors and nurses by employing international
professionals. According to strict regulation by the Thai profession council, they are
not allowed engage in clinical practice, but they are often assigned to work as
coordinators. They can combine their medical knowledge with language proficiency
to facilitate the care of international patients. This is a good example of job
transference. In 2015, ASEAN will be merged into one community; all people,
including professionals, will be able to move more easily around the region.
Information from interviews indicates Thai professionals would not move to work in
other countries; however, professionals from other countries are likely to move into
Thailand. This job transference is a good example of how they will be able to work
in Thailand under Thai professional regulations.
3. Conclusion
This chapter suggests that medical tourists do not displace domestic private patients
in terms of competing for significant resources. This study had a chance to interview
hospital executives, including directors, medical directors, marketing directors,
human resource directors, medical doctors and nurses in four private hospitals. The
key finding was that medical tourists would not displace Thai patients in private
hospitals. They receive some difference in service but this does not relate directly to
their medical treatment. Private hospitals have continued to expand their capacity to
deal with an increase in demand, but most of this increase is of Thai patients, not
international customers. However, this qualitative investigation was a smaller part of
the overall study. The findings of different perceptions, for example by Thai patients
and international patients, and the complexity involved in human resource
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recruitment, points to the likelihood of benefits from further qualitative research in
this area, which might affect resources in the public sector. Some recommendations
for policy makers are as follows:
o Resource sharing between public and private is an important issue. Many
private hospitals have reserve capacity in terms of beds and advanced
medical equipment. At the same time, public hospitals, particularly
university hospitals, always have crowded in-patient wards. It is possible
for public hospitals to use these private resources. Government should
have a clear policy enabling resource sharing among the two sectors to
maximize the utilization of spare resources without recourse to filling
beds with international patients.
o Private hospitals serving international patients should contribute to the
training of physicians, at both undergraduate and speciality levels.
Currently, the training of doctors in Thailand is mostly funded by public
investment, and the main source of doctors in private hospitals is from the
public sector. To compensate for taking public resources intended for
local patients to serve private patients, some of whom are international
patients, these hospitals should contribute to the funding of the training
process, perhaps by the introduction of a tax, specifically for the training
of doctors.
o An appropriate use of foreign professionals should be addressed to tackle
shortages in the ASEAN community in 2015. There is a need to solicit a
proper solution on how Thailand can derive maximum benefit from the
use of foreign professionals, while still protecting the interests of Thais.
o As data on taxation and other redistributive arrangements by private
hospitals is not publicly available it is hard to fully assess the costs and
benefit of medical tourism to the public system. The Thai government
should undertake a full evaluation of the medical tourism policy, which
explicitly examines the cost of private medical facilities serving medical
tourists to the public sector e. g. through the cost of human resources, and
weigh this against the benefits received through taxation and tourism
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income from medical tourists. The findings presented in this thesis mark
an important step towards this, but the absence of data on hospital income
and taxation mean they only represent a partial picture on net benefit to
the health system
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Chapter Seven
Discussion, limitations, conclusions and
policy recommendations
215
Chapter 7: Discussion, limitations, conclusions and policy
recommendations
The phenomenon of the medical tourist has emerged over the last few decades. A
new type of patient travels away from home to obtain healthcare in other countries.
The term “medical tourist” is still difficult to define. Most literature focuses on the
medical aspect. The absence of an agreed definition arises from an inadequate
understanding about the actual nature of these people, but this has not stopped the
medical tourism industry becoming increasingly important. Many countries,
particularly developing countries in Asia, Eastern Europe and Latin America, try to
position themselves as health service exporting countries. They target this niche
market to earn foreign exchange to augment their economy. Meanwhile, there have
been questions about the cost to the host country in serving these patients. Many
arguments have been raised, such as the probability of an increased internal brain
drain of skilled health personnel, the creation of a two-tier health system and an
increase in healthcare costs for local patients. However, there has been little
empirical evidence to elucidate this debate. Most literature remains based on
speculation rather than empirical evidence.
This study aims to disentangle the issues above by seeking to empirically establish
the impact of medical tourism on both the domestic economy and domestic private
health system. It tries to provide recommendations on whether a country stands to
gain or lose overall from investment in medical tourism, and to identify significant
factors which may shift this balance to ensure that a country can move closer to a
“net” benefit, by maximizing the opportunities and minimizing the risks. Two key
research questions were undertaken. The first main research question concerned what
medical tourists add to the economy in terms of medical and tourism elements, and
whether these differ from the benefits brought by non-medical tourists. The second
was what impact medical tourists have on the Thai health system, specifically private
hospitals, and how this affects domestic private patients.
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In order to answer key research questions, this study established a country case study.
Thailand was purposively selected as it is a well-known medical tourist destination.
Five leading private hospitals, being renowned in catering for international patients,
were purposively selected. These five hospitals capture approximately 65% of the
total number of international patients visiting Thailand. Three are located in the
downtown area of Bangkok, and the other two are located in high-density tourist
provinces in the eastern and southern regions of Thailand. This study focuses on
medical tourists – defined as international patients who travel to Thailand
specifically to obtain medical services. Expatriates and ordinary tourists who fall ill
during travel are excluded from the study.
324,906 electronic medical records of medical tourists in five hospitals in 2010 were
retrieved to identify their characteristics in terms of demography and service profiles,
and also their medical expenditure. 1,922,574 electronic medical records of Thai
private patients in five hospitals in 2010, and 28,013 records of non-medical tourists:
ordinary international tourists, surveyed by MOST in 2010, were also retrieved to
compare the differences, from a variety of aspects, to medical tourists. To assess the
tourism expenditure of medical tourists, information which was not available from
any other sources, 293 patients were interviewed, in order to investigate their tourism
behaviours. In addition, 15 hospital executives and 28 service providers in four
private hospitals were interviewed, to assess the possible implications for the Thai
health system.
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7.1 Discussion
This section discusses the key research findings of this study. It starts with key
findings of characteristics of medical tourists compared to non-medical tourists and
domestic Thai patients, economic impact of medical tourists and their companions,
and impact of medical tourists on domestic private patients and Thai health system.
7.1.1 Characteristics of medical tourists
Majority of medical tourists in Thailand are likely to be opportunistic tourists
This study demonstrates more understanding of who medical tourists are in Thailand.
It is apparent that the majority are not patients who travel abroad for medical
treatment entirely. Moreover, some of them do not initially identify themselves as a
patient upon arrival in Thailand. An analysis of the characteristics of surveyed
medical tourists in chapter 5 shows that only 34% of them are actual patients who
seek medical services exclusively, while half of them come with other purposes
combined with medical care, and 18% of them include medical care later when they
are in Thailand. The study of Wongkit and McKercher (2013), surveyed in eight
private hospitals in Thailand, also showed that 40% of foreign patients made their
decision to have medical services after they arrived Thailand [146].
They tend to come for simple problems as out-patients. An analysis on the service
required in Chapter 4 demonstrates that the largest group of them, approximately
34% male and 41% female patients, come for health check-up and medical
consultation. This information shows that, for out-patient, they may not be an actual
medical tourist, who actively seeks medical care for more serious and complicated
conditions, but perhaps are more accurately termed “opportunistic” tourist who has
dropped-in for non-urgent medical care. In contrast, for in-patient, they are likely to
be a “genuine” medical tourist as their average medical expense for in-patient is
much higher, approximately 3-fold that of Thais. This implies that they are admitted
with more complicated diseases.
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Most literature tries to define medical tourism under a health category, by focusing
on patients’ motivations for seeking care abroad, the procedures they have, and other
issues related to healthcare [5]. However, in the case of Thailand, the majority of
foreign patients who receive medical services are “opportunistic” tourists. They
either initially include medical services as only one of the purposes of their trip, or
include them later after their arrival in Thailand.
The actual number of “genuine” medical tourists is far fewer than has been
previously suggested
According to current information, estimated by health and trade policy makers,
approximately 1.5 million international patients visit Thailand every year. This is
generally interpreted to mean that Thailand serves an additional 1.5 million fly-in
patients, “medical tourists” in other words, every year. This number of patients has
been used for estimating their present and future contribution to the national
economy. Na Ranong et al (2011) employed this data and estimated that international
patients generated 46-52 billion THB in 2008 and 59-110 billion THB in 2012 [10].
Unsurprisingly, these considerable revenues attract the attention of the Thai
government. The policy of making Thailand into a hub of medical service in the
region was established in 2004. At the same time, the prospect of a large number of
patients arriving in Thailand created great concern for health policy makers and
health NGOs on how much this influx might affect domestic patients.
Currently, a blurred interpretation of the terms “international patient” and “medical
tourist”, which are the main targets of the “Medical Hub” policy, remains. Trade
policy makers, who usually support the policy, and NGOs, who are usually against it,
make the unintentional assumption that the number of international patients is the
same as the number of medical tourists, so both the positive and negative
implications of serving medical tourists are usually overstated. The main reasons for
data misinterpretation are multiple counts and medical tourists being included in
other groups of foreign visitors. Existing data concerning international patients
surveyed by the Ministry of Commerce was collected from 55 hospitals all over
Thailand serving these patients, mostly private hospitals. All these hospitals reported
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the number of foreign patients obtaining services according to the number of separate
visits, rather than by the number of patients actually treated. As one patient may visit
a hospital several times over the course of a year, the reported data doesn’t reflect the
actual number of patients accurately. As Connell (2013) mentioned, the number of
medical tourists is usually inflated by the inclusion of all types of international
patients, including expatriates, diaspora patients, and tourists who happen to have
fallen ill during their holiday [5].
In Chapter 4, an analysis of international patients obtaining services in the five
private hospitals in 2010 confirms the above arguments. There were 911,913 visits of
international patients to the five private hospitals in 2010. This number is around
60% of the number of international patients (1.5 million) estimated by the MOC
survey. The study shows that the actual number of international patients in the five
hospitals was around 236,885 patients with an average utilization rate of 1.85 visits
per patient per year. Of this number, only 44% were medical tourists, making 3.1
visits per patient per year. 31% were expatriates, while 25% were international
tourists who happened to fall ill while travelling in Thailand.
To estimate the total number of actual medical tourists in the whole country, an
assumption was made that international patients in all hospitals had the same
proportion of medical tourists using facilities at the same rate. Hence, based on the
figure of 1.5-2 million visits by international patients, there would be approximately
172,000-223,000 actual medical tourists. Thus, the actual number of medical tourists
is considerable lower than is generally suggested.
Fewer hospitals in Thailand have engaged in the medical tourism industry
The government “Medical Hub” policy has led to the development of Thai hospitals
particularly in the private sector. Many private hospitals promote themselves as an
“international” hospital. Not only is the term “International” usually added to their
name, but infrastructures are also renovated. International quality assurance, mostly
by JCI, is applied as a trade mark of internationality.
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The MOC survey reported that at least 55 hospitals served international patients in
2007. The top five of these hospitals are included in this study. In 2007, Bumrungrad
International Hospital had the largest share of international patients: 426,398,
accounting for 31% of that year’s total. Ranked fifth was Bangkok Phuket Hospital,
with 58,941 international patients, 4.3% of the total. This survey found that other
hospitals had a very small market share, most of them less than 1% of the total
number of international patients. Thus, the five hospitals in this study captured the
majority of the international patient market in Thailand.
As mentioned before, all international tourists are categorized into three main groups,
medical tourist, expatriate and tourists who fall ill while visiting Thailand. Analysis
of the proportion of medical tourists in each hospital showed only three hospitals out
of the five hospitals with more than 30% (Figure 7.1). The first hospital had 56%, the
second hospital had 49% and the third had 30%. The other two had only 15% and
12% respectively. This implies that there are very few hospitals engaging heavily in
the medical tourism industry in Thailand. Most of them served mainly expatriates,
while hospitals in high-tourist areas served mainly international tourists who fell ill
while visiting Thailand.
Figure 7.1: International patients by categories in each hospital
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hosp1 Hosp2 Hosp3 Hosp4 Hosp5
Being‐ill tourist
Expatriate
Medical tourist
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Medical tourists differ from Thai private patients in demography and services
required
Understanding the characteristics and service patterns of medical tourists allows the
forecasting of demand, and assesses their impact on the domestic private health
system. As mentioned before, a limited literature provides institutionally-derived
information on these issues. Mostly, the treatment of these patients occurs in private
hospitals where information is difficult to access.
The analysis of medical tourist characteristics in Chapter 4 shows that they differ
from Thai private patients. In terms of demographic profiles, they are older than
Thais and tend to be male. Almost 60% of medical tourists are male patients and
their average age is 41.7. In contrast, 60% of Thai patients are female and their
average age is 37.2. In terms of service profiles, they have comparatively different
disease patterns and types of operation needed. The largest group visit hospitals for
health check-ups, medical consultations and follow-up treatment: approximately 34%
of these are male and 41% female. Apart from these services, their types of health
problems also differ from those suffered by Thai male and female patients. In terms
of procedure, male medical tourists receive comparatively similar types of procedure
to Thais, but there are differences in the procedures undergone by female medical
tourists and female Thai patients. As some of the medical tourists are “genuine”
patients who seek economical and prompt medical care, this group needs more
operations and longer stays in hospital when compared to Thais. An analysis of
procedures shows that they have 2-2.5 fold higher operation rates when compared to
Thais. Both male and female medical tourists tend to stay in hospital longer than
Thais – with average LOS of 6.6 and 5 days per patient per year respectively.
Though medical tourists require somewhat different services to Thais, they may still
compete with Thai private patients for some resources. An analysis shows that dental
care, cosmetic procedures and heart-related procedures are more popular with these
overseas patients. Nonetheless, Thai patients have more choice of services related to
these procedures; for example, in public hospitals and other private clinics an
increase in demand from medical tourists would displace some Thai patients to some
222
degree. An analysis of patients obtaining services in the five hospitals also shows
that Thai patients are still in the majority, accounting for 68%, while 14% of patients
are medical tourists. Though medical tourists would compete with Thais for some
resources, their overall impact would be very marginal.
Long-haul medical tourists are different to within-region medical tourists
Though it is difficult to precisely define “medical tourists”, there is evidence that
such persons are largely regional, cross-border and diasporic in their movement [5].
Familiarity with the health system, a common language, and the ability to access
cheaper treatment are the main contributing factors. Connell (2013) reports that
medical tourists are more likely to be intra-region patients or from the diaspora,
while the “White” or Western patients were fewer in number than expected.
However, there is still limited empirical evidence to support this view.
In the case of Thailand, this study confirms that the regional effect still has great
influence. In 2010, 70% of medical tourists in the five hospitals were from within-
region, including countries in Asia and the Middle East. The largest group were from
the Middle East (39%), followed by Southeast Asia (14%) and South Asia (12%).
30% were long-haul, these source regions including North America, Europe,
Australia and Oceania. This is because two of the hospitals in this study are located
in a predominately Middle Eastern neighbourhood in central Bangkok, facilitating
close informal links and advertising. Europe, North America and Australia are the
main long-haul points of origin. Patients from Europe are the largest group,
accounting for 13%.
Differences in health behaviour and healthcare infrastructures, such as available
health facilities with highly-qualified staff, between long-haul and within region,
create a difference in the characteristics of patients seeking healthcare abroad. An
analysis of medical tourists among regions demonstrates that patients from long-haul
regions including Europe, North America and Australia tend to have similar
characteristics, while those from local regions, including Southeast Asia, other parts
of Asia and the Middle East, tend to share similar characteristics also. Patients from
223
long-haul regions tend to be older than those from within local regions. The oldest
are those from North America (45.35 years) and the youngest are from the Middle
East (39.19 years).
Patients from long-haul regions tend to stay in hospital for a shorter period. Average
LOS for Europeans is 5.36 days per patient which is the longest stay among the long-
haul group, while average LOS for Australians is 2.32 days per patient. This implies
that patients from Australia arrive with less serious conditions compared to those
from other long-haul regions. Interviews with service providers supplied clarification
that most Australian patients, particularly female ones, come for cosmetic procedures
and they usually include medical services as part of their holiday in Thailand.
Patients from the Middle East stay in hospital for the longest period, with an average
LOS of 10.53 days per patient. They seek quality services which are unavailable in
their countries. An analysis on length of stay shows that 3.6% of them stayed in
hospital for more than 30 days. Those from the Middle East were the biggest group.
30 days is the maximum period foreign tourists are allowed to stay in Thailand. This
regulation has been considered a barrier to the growth of the medical tourism
industry in Thailand.
Heart-related procedures, including cardiac catheterisation, coronary angiograms and
other cardiac operations are popular with those from local regions, while cosmetic
procedures are more popular with those from long-haul regions. The difference in
services required by the two regions results from the domestic health services
available in their countries of origin. Advance tertiary care with a high quality of
service is unavailable or difficult to access in countries within region, such as the
UAE, Myanmar, Bangladesh and Cambodia. Patients from long-haul countries seek
cosmetic procedures not covered by health insurance, and also cheaper heart-related
procedures.
All these different characteristics seem not to be taken into account by policy makers
at national level. As described earlier, there is a lack of empirical evidence on the
nature of medical tourists in Thailand, particularly at national level. Hence, most
policy makers focus only on the overall number of foreign patients rather than
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breaking them down into specific segments. However, it is different for policy
makers at the hospital level. Information from the interviews undertaken during this
study shows that hospital executives closely monitor many of the characteristics of
their foreign customers, such as country of origin, disease pattern and type of
procedure received, in order to prepare effectively for service provision and
marketing in the future.
Medical tourists have a different demography from non-medical tourists
This study tried to investigate the tourism behaviour of medical tourists. There is a
need to understand whether they are unique patients who intentionally visit Thailand
for medical care, or whether they are tourists who just use drop-in medical services
when they are in Thailand.
An analysis of both medical tourists and non-medical tourists shows that these two
groups seem comparatively different. In terms of region, medical tourists from the
Middle East, Southeast Asia and Europe are in the majority, while among non-
medical tourists, those from Southeast Asia, Europe and East Asia are in the majority.
Tourists from Southeast Asia make up the largest group among non-medical tourists,
and tourists from Malaysia are the largest group of these, accounting for 13% of the
total number of non-medical tourists. This is because they live in neighbouring
countries, and it is easy to cross the border into Thailand. This group is followed by
that of tourists from Europe and East Asia. As mentioned in the previous section, the
Middle East is the main region of origin of medical tourists. Patients from UAE are
the largest group of these, accounting for 20% of the total number of medical
tourists. Patients from the Southeast Asia region rank second, accounting for 14%;
most of these are from Myanmar and Cambodia, accounting for 7% and 4%
respectively. There are very few patients from Malaysia, as Malaysia has a good
health service and the Malaysian government has promoted the country to the
medical tourism industry. Meanwhile, there are many tourists from East Asia,
including China, Japan and South Korea, visiting Thailand, but they are not much
interested in receiving medical care there. Apparently, South Korea is also positioned
as a medical tourist destination. The MOC report stated that the Japanese are in the
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top five of foreign patients in Thailand. This may be true, as many Japanese reside in
Thailand, but they visit hospitals as an expatriate rather than as a medical tourist.
Moreover, Southeast Asia and Europe are overlapped among two groups. It would be
fair to say that the links between being a patient and being a tourist need further
investigation.
7.1.2 The economic implications of medical tourists
Overall, medical tourists and their companions contribute to the Thai economy
Findings from Chapter 5 suggest that medical tourists and their companions
contribute, overall, to the domestic economy. Medical tourists spend on medical
expenditure, which is their main purpose of travel. The patient survey indicates that
their companions also engage in medical services, spending about 23,800 THB per
person on these services.
Furthermore, the findings of this study show that a medical tourist is not only a
patient seeking healthcare services outside their own country, but someone who
engages in a considerable number of tourism activities. From the service providers’
view, hospital executives and other service providers, particularly those at hospitals
in tourism destination areas, confirm that these patients combine tourism with their
medical treatment. On the other hand, from the patients’ view, some of them said that
they made a decision to seek medical treatment while they were in Thailand. From
this point of view, they are opportunistic tourists receiving medical care. When being
a patient or being a tourist, they engage in both medical and tourism activities. This
generates more revenue to the national economy. Moreover, spending on tourism by
both patients and their companions has a substantial effect on the economy. Tourists
contribute to destination sales, profits, jobs, tax revenues and income. There is a
direct impact on primary tourism sectors, such as accommodation, restaurants,
entertainment and retail shops, while other sectors are impacted by a secondary
effect.
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Concerning each medical tourist, more revenues are generated when compared to
either a Thai patient or a non-medical tourist. However, the actual number of medical
tourists was found to be not as high as expected, so overall, revenues from medical
tourists are still marginal when compared to those generated by Thai patients and
non-medical tourists.
Medical tourists spend more on medical expenditure than Thai private patients
An analysis of medical expenditure in Chapter 5 suggests that medical tourists spend
more per patient than Thais. For out-patient clinic services, medical tourists spent
around 24,520 THB on average, while Thai private patients spent around 15,280
THB. As mentioned in the previous section, medical tourists in out-patient clinics
tend to be a mixture of actual patients who seek medical care exclusively and those
tourists receiving medical treatment during their holiday. Their disease pattern is
comparatively simple, comprising uncomplicated conditions which result in slightly
greater expense compared to the expense of the conditions suffered by Thais.
In contrast, medical tourists spent much higher amounts on in-patient care than
Thais. The average in-patient expenditure of medical tourists was 353,460 THB,
while average in-patient expenditure for Thai patients was 120,880 THB. This
finding strengthens the argument that foreign patients who seek treatment are likely
to be genuine medical tourists. They visit Thailand with complicated conditions that
require hospitalisation and invasive procedures; the findings in Chapter 4 elaborate
this argument. Medical tourists have a higher operation ratio (number of procedures
per patient) than Thais – twice the number in men and 2.5 times the number in
women.
For regional comparison, within-region medical tourists spent more than those from
long-haul regions – 1.22 times more for out-patient services, and 1.33 times more for
in-patient services. Patients from within the local region stay for longer than long-
haul ones; hence, these patients are the most lucrative customers for the medical
tourism industry in Thailand.
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Medical tourists and their companions spend more per person on tourism than
non-medical tourists
This study aimed to investigate how much medical tourists increase the tourism
market, what they tend to spend and on what items. An analysis from the patient
survey in Chapter 5 demonstrates that medical tourists spend much more on tourism
than non-medical tourists: excluding all medically-related elements, around 82,520
THB per person; while non-medical tourists spend around 31,970 THB per person.
The reason behind this difference would appear to be that medical tourists are
comparatively better-off, from the evidence that they can afford medical care abroad,
so they are also able to spend more on tourism compared to ordinary tourists (many
of whom are ‘backpackers’). Similarly, tourists who receive opportunistic medical
care while on holiday are likely to be affluent tourists rather than backpackers.
However, this issue needs further study for a deeper understanding of their
demography and tourism behaviour.
The patient survey in Chapter 5 also found that medical tourists tend to travel with
companions. Half the medical travel with an average of 2 companions. Surprisingly,
companions spend around 80,351 THB per person on tourism, which is again much
higher than the spending of non-medical tourists.
An analysis of tourism spending profiles shows that medical tourists and their
companions spend much more in all tourism categories than non-medical tourists.
Medical tourists had an average tourism spending per day of around 8,440 THB,
while their companions’ expenditure was 9,080 THB. Non-medical tourists spent
much less – around 4,190 THB per day. Accommodation, food & drink and shopping
are the main tourism categories in which medical tourists and their companions
spend. The study also found that medical tourists engaged in shopping and
recreational activities such as sight-seeing and entertainment. This finding contrasts
with the view expressed by Whittaker (2008) asserting that the term “medical
tourism” is a misnomer, encompassing as it does the idea of recreation, which does
not correlate with illness [75]. This study has found that medical tourism, to some
extent, does include pleasure as part of the medical travel.
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7.1.3 Impact of medical tourists on the health system
Information is commercially sensitive and confidential
Information on resources and revenue allocation is commercially sensitive and
confidential; hospitals do not openly reveal how they obtain new resources
specifically for medical tourists, how they allocate resources among Thais and
foreigners, and how they allocate the revenues generated by treating foreign patients.
This study employed secondary data, publicly accessed, which could not provide
much rigorous information. Further research on these issues is needed to deliver
deeper understanding.
There is no difference in critical aspects of care between Thai and international
private patients
Difference in service provision between patients is a sensitive concern, meaning that
hospitals provide different standards to some of their patients, which may not ensure
overall quality of service, especially for domestic patients. The issue of
discrimination is an important element of the quality assurance system for national
and international quality accreditation agencies. Hospitals aiming to serve foreigners
try to achieve an international standard of quality as the “trade mark” to promote
their hospitals. In Thailand, currently, there are 22 hospitals accredited by JCI. All
hospitals in this study are already accredited by JCI.
The findings presented in Chapter 6 show that there is no difference in the critical
aspects of care delivered to foreign and Thai patients. All patients are provided with
the same medical guidelines for treatment, the same procedures and the same choice
of drugs. However, there are some differences in terms of peripheral areas of care,
due to the “tourism” element, such as translators, transfer services and special food.
Moreover, foreigners tend to require more time allocation from doctors and nurses
because of difficulties in communication. These differences do not affect the quality
of medical service, and foreign patients have to pay extra to cover the additional
services.
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Hospitals employ their spare capacity to serve the demand of international
patients
Competition for resources between foreign and Thai patients is a great concern for
health policy makers, especially as medical tourists might appropriate resources that
would otherwise have been available for locals. However, the increased demand for
health care occasioned by medical tourists may simply be met by health care
providers who already had sufficient spare capacity to deal with the increase. It is
therefore important to investigate whether additional resources are actually
transferred from the domestic public sector, and therefore whether medical tourists
do displace domestic patients.
The study findings presented in Chapter 6 show that hospitals employed a variety of
strategies when allocating resources to service the increased demand of international
patients. Most hospitals utilised their spare capacity to provide services for foreign
patients. Information from the Bureau of Policy and Strategy, MOPH, shows that the
bed-occupancy rate of private hospitals in Thailand in 2008 was 60%, an increase
from 54% in 2006. The same report also reported that the bed-occupancy rate in
hospitals under MOPH during 2008 was 83%. This meant that private hospitals still
had sufficient spare capacity to cope with increased patient demand. Hospitals in
Bangkok Dusit Medical Services Company, including Bangkok, Bangkok Phuket and
Bangkok Pattaya hospitals, had spare bed-capacity at this time. In contrast,
Bumrungrad Hospital had very limited bed-capacity. At the time of this study, they
were planning to construct a new building in a nearby area to expand their capacity
to treat for both Thais and foreigners.
HRH for serving international patients are mostly recruited from domestic
sources
Human resources for health (HRH) are considered a potentially critical negative
implication arising from medical tourism, as they are comparatively limited,
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particularly in the developing countries which are becoming medical tourist
destinations. Thailand has experienced a shortage of HRH for several years.
Interviews with hospital executives suggested that their hospitals were continuously
expanding the capacity of their health professionals in order to cope with the
increasing demand of patients. They required high-calibre doctors in a variety of
different fields. The more specialized the professionals required, the greater the need.
Hospitals serving foreigners mostly provide comprehensive tertiary medical care.
They also require highly-skilled nurses to care for patients suffering from
complicated conditions. Meanwhile, health professionals in Thailand are mostly the
products of public investment; there are 16 public and 1 private medical school, and
64 public and 10 private nursing schools. Medical and nursing students pay their own
tuition fees, which are much less than their actual cost, during their period of study.
However, world-class private hospitals do not employ these new graduates: they
want experienced medical and nursing specialists, and obtain them by recruiting
from medical schools and public tertiary hospitals. At the same time, there are
shortages of these specialists in the public sector. Hence, an expansion of human
resource capacity in private hospitals depletes the resources of public services.
However, it is arguable whether this is a direct result of the increase in demand by
foreign patients, as these specialists serve both Thai and foreign patients at the same
private hospitals.
The findings in Chapter 6 suggest that some hospitals use foreign resources to cater
for the demands of international patients. For example, in terms of medical
equipment, all hospitals have expanded their capacity to serve an increased demand
by patients, and to provide access to new medical technologies at a global level, by
importing advanced and sophisticated medical equipment. Some hospitals have
recruited Thai doctors who have been working in other countries, mostly the USA. In
addition, some hospitals have recruited foreign doctors and nurses to work in non-
clinical roles; these professionals are not permitted to engage in clinical practice
under the regulations of the Thai professional council. Instead, they work as
physician and nurse coordinators, combining their medical knowledge with their
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language abilities to assist patients in arranging a treatment plan. This is an effective
approach to the employment of foreign professionals in Thai hospitals.
According to tax law, very few revenues from foreign patients are allocated back
to the public sector
Though Thai patients predominated in all the hospitals in the study, in terms of
revenue, at some hospitals medical tourists dominate. In 2012, 61% of hospital
revenues in Bumrungrad International Hospital were from foreign patients. In
contrast, approximately 30% of hospital revenues in BDMS were generated by
foreigners. Regarding two findings, between 30-60% of hospital revenues in the five
hospitals were derived from the treatment of overseas patients.
Data from hospital financial reports showed that most hospital income was spent on
hospital operations and 15-20% was allocated to administrative costs. As all hospitals
in this study were listed on the stock exchange, 12-14% of their income was
allocated to share-holders; 5% of their revenue was paid to the government as
corporate tax. This direct income is considered to represent an insignificant figure
compared to the total income generated by foreign patients.
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7.2 Limitations of the study
7.2.1 Sub-study 1
o Diversity of sources of patient data
A limitation of this analysis was the number of hospitals included in the study. They
were selected from the list of hospitals surveyed by the MOC in 2007. According to
MOC data, however, the number of private hospitals involved in this survey was the
highest; in subsequent years, fewer hospitals were surveyed. This implies that the
data from 2007 may be more complete than that from other years. Another
consideration related to the number of hospitals involved in this study is although it
included five hospitals, four were operated by the same company, under the same
principles; consequently, information obtained from this group of hospitals was
likely to be very similar. In addition, this study employed data from the year 2010;
the medical tourism industry in Thailand has grown rapidly since then, along with
the improvement in the Thai economy. Thus, the current picture of medical tourists
may differ slightly from that presented in this study.
o Incomplete diagnosis of patient data, particularly out-patient
Regarding data of medical tourists and Thai private patients from the five hospitals,
the overall data is reasonably complete, as there is a good managerial system in the
private sector. However, some information on the diagnosis of out-patients is still
missing, although information on in-patients is definitely complete. This should be
kept in mind when interpreting information on patient diagnosis.
o Accuracy of non-medical tourist data
This study used data from the MOTS survey, being the only available source in
Thailand. All information about international tourists depends on the accuracy and
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presentation of this data. It would have been better if this study had been able to
analyse the data of an actual population of international tourists.
7.2.2 Sub-study 2
The main limitation of this section concerns the patient survey of tourism
expenditure. Not only is it quite difficult to conduct a survey in private hospitals, but
patients there, particularly international patients, are particular about privacy. To
enhance their participation, this study used hospital staff, mostly nurses and
interpreters, as interviewers. Two key reasons were that patients were comfortable
with them as they were in hospital uniform, and that communication in a variety of
languages would be easier. Despite this, some patients still declined to participate.
This problem also arose in the MOTS survey. Regarding time limitations, this study
included 293 participants, 50.7% of the required sample. Nonetheless, it is worth
remembering that this study has still managed to recruit a larger sample size than any
previous studies.
Given the limitations described above, participants in this survey tended to be from
comparatively lower income groups. The largest group were agricultural workers,
accounting for 18.6%, followed by administrative and managerial professionals,
accounting for 17.5%. One reason is this group tended to engage more easily with
the survey than more wealthy patients. Participants would therefore not necessarily
be the best representatives of the wider population of medical tourists. On the other
hand, in terms of policy implications, the actual expenditure of medical tourists
would be likely to be higher than those findings from this study. However, it is
necessary to remain careful in interpreting and utilizing the findings.
Information on tourism expenditure was obtained by asking patients to recall their
spending in each category up until the day they went into hospital. Hence, this figure
may be less than the amount they actually spent during their visit. The difference also
depends on the length of the period between the day they were interviewed and their
departure from Thailand. It was too complicated and costly to monitor patients
during this period.
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7.2.3 Sub-study 3
This section tries to show whether, and to what extent, foreign patients create any
implications for the Thai health system from interviews with hospital executives and
service providers. Though staff from only four hospitals were interviewed, out of
more than 55 hospitals reported as providing services to foreign patients, these were
the key hospitals engaged in the medical tourism industry in Thailand. Many private
hospitals in Thailand operate in alliance; three of those in the study were part of the
same company. However, each had management autonomy. Information from
interviews shows that, though they shared common policies, there were many
differences between these hospitals in serving foreign patients. Hence, information
derived from these four hospitals is rich enough to demonstrate the implications of
foreign patients at national level. However, further study focusing on patients would
provide deeper insights into patient perceptions.
As the service providers: the doctors and nurses in these interviews, were selected by
the hospitals themselves using the study criteria, sample bias could have occurred.
Hospitals may have deliberately chosen staff with positive views on international
patients. However, most of the interview questions asked for the facts of their routine
work, and very few questions asked for the interviewee’s personal opinion.
Moreover, their information was triangulated with that of others, and both positive
and negative accounts relating to foreign patients emerged during the interviews.
This study was unable to interview a hospital CEO. However, all the hospital
executives interviewed were on the executive board and were able to provide
information on hospital policy. In addition, the study tried to select hospital
executives from a variety of roles to ensure diversity of information and also to
triangulate for data validity. Hence, information derived from them is rich and
diverse.
Though this study tried to mitigate bias during data collection and data analysis,
some biases no doubt remain. Participants were purposely selected hospital
executives and service providers who were likely to provide good information.
235
However, it might not represent ‘real’ practice. For example, information on
discrimination in treatment may be more likely to be raised by Thai patients than
professionals from the hospitals serving them.
Detailed information on the resources obtained to serve the demands of foreign
patients was inaccessible. This study tried to explore how these resources were
obtained, for example from domestic or foreign sources, by investigating secondary
hospital data. For reasons of confidentiality, this information was not available to
researchers. However, the study used secondary data from public source, such as
hospital annual and financial reports, for data triangulation. The primary investigator
sometimes picked up interesting issues from this secondary data and sought further
explanation during interviews.
7.3 Conclusion
Globalization has created a free movement of patients travelling around the world for
cheaper, better and prompter services, and this is likely to continue as long as
differences in health services in each country remain. Unsurprisingly, this is resulting
in the rapid growth of the medical tourism industry in many countries, in order to
capture these lucrative customers. Thailand has already engaged in this profitable
market. The perceived success of the “Medical Hub” policy during 2004-2008
encouraged the Thai government to continue the second phase of this policy, while
many concerns about possible negative implications still remain.
In order to continue with this policy, there is a need for the Thai government to
carefully consider its overall “cost”. The direct cost includes all costs related to
operating activities, costs of the tax incentives given to the private sector for
investment in the infrastructures serving foreigners, costs for marketing, such as
international road shows, advertising campaigns and websites. The findings of this
study indicate that medical tourists do directly contribute to the national economy. It
is apparent that each medical tourist and any companions spend a lot, not only on the
medical element of their visit, but also on tourism elements. They are profitable
customers to Thailand as, in terms of medical services, they spend more than Thais
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and, in term of tourism, they also spend more than general international tourists.
However, the key important finding is that the overall number of “genuine” medical
tourists is far less than generally believed. They should be considered as a niche
market compared to the substantial number of non-medical tourists visiting Thailand
every year. Hence, overall revenue from them is very marginal compared to overall
revenue from non-medical tourists. It is very important to consider the the net benefit
gained from pursuing the policy of encouraging medical tourists, in order to ensure
Thailand will gain from serving them.
As medical tourists are non-homogenous, the next medical hub policy should
perhaps be smarter. Market segmentation is needed. Rather than a broad and general
policy covering all customers, it should directly identify specific profitable groups. A
second priority is to enhance the revenues generated from medical tourism. To
maximize these revenues, collaboration between the health and tourism sectors is
essential. The varied nature of the medical tourist in Thailand provides a great
opportunity. The majority are tourists who add medical services to their trip either in
advance, or on arrival. At present, Thailand has 22 million international tourists
annually. It would be a great challenge to encourage them to engage in health
services. Health products should not focus only on advanced and sophisticated
medical care, but expand to include simple and less invasive services, such as health
check-ups and one-day procedures in dental and cosmetic care, which would be easy
for tourists to add to the main purpose of their visit.
However, an indirect implication of medical tourism is its effect on the domestic
health system. It might create a shortage of high calibre doctors in medical schools
and public tertiary hospitals, especially among some specialists, such as
orthopaedists, heart surgeons, plastic surgeons and dentists. It is difficult to assess
how far this would impact on the domestic health system, particularly on HRH.
Further study is still needed in this respect. Many strategies could be established to
mitigate this effect, such as well-prepared policies and comprehensive human
resource planning. Furthermore, the private sector could contribute more to HRH
production. However, this problem is not directly a medical tourist issue, but it is
really a public-private issue.
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7.4 Recommendations
7.4.1 Policy recommendations
1. Combining a medical element with the tourism industry
Findings show that only 0.5% of international tourists came to Thailand with a
primary healthcare purpose. However, it is apparent that some of them engage in
medical services after arriving Thailand. This is an opportunity for government to
link medical activities to the tourism industry. One approach might be to promote
simple medical packages, such as physical check-ups, simple dental procedures and
simple cosmetic procedures, through the Tourism Authority of Thailand offices
located in big cities around the world, and through world-wide travel agencies.
Promotion of medical-services packages in tourism settings such as planes, hotels
and other relevant locations may be an additional route to recruiting patients.
2. Promoting tourism packages to medical tourists and their companions
Though some medical tourists and their companions still engage in tourism, private
hospitals do not provide well-organised tourism package for patients. It would be a
good opportunity for hospitals to coordinate with local travel agencies to provide a
tourism package specifically suited to individual health conditions. A tourism section
advertising a variety of recreational activities should be added to hospital websites,
enabling patients to find out what other activities they could engage in while they
and their companions are in Thailand.
3. Emphasizing market segmentation
As medical tourists are non-homogenous, a new medical hub policy should not be a
broad campaign for general patients but should be more focusing on specific groups
according to region, gender and age, in order to maximise revenue from these
lucrative tourists. Policies should focus on how to recruit tourists through “medical
elements”. The following are some recommendations;
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3.1 Attracting non-medical tourist from East Asia as a new market for medical
tourism industry
Tourists from East Asia rank third in the numbers of tourists visiting Thailand,
accounting for 23% of total international tourists, but they rarely engage in
medical services. Policy should target this group to increase their participation in
health services.
3.2 Focusing the attention of medical tourists from within region on heart-related,
digestive and orthopaedic procedures
Patients from within-region tend to be more lucrative than those from long-haul.
They visit Thailand for services which are not available in their home country.
Heart-related, digestive and orthopaedic are the most popular procedures for
them.
3.3 Focusing the attention of medical tourists from long-haul regions on cosmetic
and heart-related procedures
The most popular procedures for patients from long-haul regions are cosmetic
and heart-related. Most Australian patients visit Thailand for cosmetic
procedures and these, considered as less invasive operations, would combine
well with a tourism package to increase the value-added aspect.
3.4 Providing medical service packages for long-haul patients
Long-haul patients are likely to visit Thailand using medical service packages.
To attract them, packages such as those providing cosmetic and dental treatment,
would be the most appropriate.
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3.5 Targeting men and older patients
Based on their disease patterns, men and older patients engage in a variety of
medical treatments. Some need more serious operations such as heart and
orthopaedic procedures, and could contribute considerable revenue through
medical expenditure.
4. Extending visa period in Thailand for medical tourists
There is a need to extend the period foreign patients are allowed to stay in Thailand,
as currently some need to stay in hospital longer than the period officially permitted.
This extension will facilitate patients with complicated conditions and allow them to
complete their treatment; this will particularly help patients from the Middle East.
Though the study shows that only 3% of the total number of medical tourists is in
this group, there is a need to loosen this legislative barrier for when planning to serve
this lucrative age group in the future.
5. Increase private sector contributions to HRH production
The training of health professionals is mostly funded by public investment,
especially that of doctors. An increased demand for health professionals to meet the
demand from either Thai or foreign patients, results in pressure on resources from
public sources. To redress the balance, there is a need for private hospitals to
contribute more to HRH production. One approach would be to increase corporate
tax from hospitals serving foreign patients.
7.4.2 Recommendations for research priorities
Many issues are commercially confidential and it is difficult to access important
information, particularly on resource allocation in private hospitals. Research in the
future is still needed to reveal information on issues on which data are currently
indistinct.
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1. A cost-benefit analysis
This study provides initial information concerning medical tourists in Thailand. It is
the first study providing strong empirical evidence about medical tourism and its
possible implications. However, data on taxation and other redistributive
arrangements in private hospitals is not still publicly available. There is a need to
investigate the cost to the public sector of serving medical tourists. Further
understanding of the likely net benefit of medical tourism to the country requires a
comprehensive cost-benefit analysis, looking more closely at the costs of the policies
enacted to encourage and service medical tourism, compared to the range of benefits
such as those reported here.
2. The implications of medical tourists diverting medical specialists from local
patients
A key concern for health policy makers is the extent to which medical tourists effect
the movement of specialists from the public to the private sector. This study focused
its investigation on private hospitals, so cannot assess the possible impact on the
public sector. It would be valuable to explore this issue.
3. Study of medical tourists’ views on why they chose Thailand
A study of medical tourists’ perspectives on their reasons for choosing Thailand,
rather than another country, as a destination for medical service, should be
conducted. Findings from that study would help to strengthen the country’s
competitiveness in the global medical tourism industry.
4. A study on the impact of international patients from bordering countries
This study focuses on foreign patients served in world-class private hospitals in
Thailand. These prosperous patients are the main target group of the “Medical hub”
policy, and also the same target group of all medical tourist destination countries, as
241
they generate national revenue. However, some international patients from bordering
countries are also seeking health services, mostly in public health facilities. Most
cross-border patients are in the poor to middle-income category. Providing services
for these patients would generate very little revenue, but they are still likely to
directly compete for health resources with domestic public patients, particularly the
poor. A study of this issue would provide another perspective of the impact of
international patients.
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Annexes
Annex 1: Ethic committee approval
Annex 2: Information sheet and consent form for patient survey (in English,
Arabic and Japanese)
Annex 3: Questionnaire for patient survey (in English, Arabic and Japanese)
Annex 4: Information sheet and consent form for interview (hospital executives
and service providers)
Annex 5: Semi-structured questions for interview (hospital executives and
service providers)
Annex 6: List of interview participants
Annex 7: Country comparison on characteristic of medical tourists
254
Annex 1: Ethical committee approval
255
Annex 2: Information sheet and consent form for patient survey
1. English language
256
257
2. Arabic language
258
259
3. Japanese language
260
261
Annex 3: Questionnaire for patient survey (in English, Arabic and Japanese)
1. Questionnaire in English language
Questionnaire for the 2011 Medical Tourist Expenditure Survey
This is a Survey on Medical Tourist Expenditure 2011, which is conducted by International Health Policy Program, Ministry of Public Health Thailand. The survey includes questions mostly on your travel expenditures in Thailand. It may need your time and some effort to complete. Your participation in this survey will help us in planning for improvement of Thai tourism and medical tourism industry. Your responses will be kept strictly confidential and for research purpose only.
Thank you
Part 1: Data on Travel Expenditures 1. In which country do you live? …………………………………………………….
2. Have you been to Thailand for medical care before? [1] Never before [2] once or twice before [3] more than 3 times
3. Number of days that you spent in Thailand …………………days.
4. Number of days you stayed in hospital......................................days (for inpatients only)
5. Are you in Thailand on a package of medical services? [i.e. a package in which at least includes medical service cost, air fares and accommodation prepaid before departure] [1] Yes
[2] No, I'm self organized this trip
[if your answer is NO, please go to question No.7]
6. How much did you pay for this package of medical services (for 1 person only)? …………....... [Indicate currency]
Please check the items that are included in the package of medical services
[1] International air/bus fares [2] Transfer
[3] Medical costs [4] Accommodations
[5] Food & Beverages [6] Sightseeing
[7] Medical services [8] Other [Specify] …………….............
262
7. By which airline[s] did you use for travel into and out of Thailand and how much did you pay for the air fare (1 person only)?
7.1 Into Thailand, air fare cost………….……………… [Indicate currency]
[1] Thai airways [2] Other airlines
7.2 Out of Thailand, air fare cost ……….……………... [Indicate currency]
[1] Thai airways [2] Other airlines
8. How much in total did you spend on the following items on this visit to Thailand? Please make sure that you include all methods of payment (cash, credit cards, travelling cheques, etc.). If you are on a package of medical services, make sure this amount excludes the package tour you bought.
Types of Expenditure Total
[Indicated currency]
1. Local transportation [by domestic fare, etc.]
2. Accommodation [exclude hospital room services]
3. Food & Beverage
4. Sightseeing [domestic tour, etc.]
5. Shopping
6. Entertainment and leisure/sport activities
7. Medical care [ include hospital room services]
8. Other expenses [convention fee, etc.]
Total
263
Part 2: Data on Travel Expenditures of your companions/relatives
9. How many companions or relatives come with you in this trip? .....................person[s]
10. How much in total did your companions/relatives spend on the following items on this visit to Thailand? Please make sure that you include all methods of payment (cash, credit cards, travelling cheques, etc.).
Types of Expenditure Total
[Indicated currency]
Expenditure of
No. of persons
1. Local transportation [by domestic fare, etc.]
2. Accommodation
3. Food & Beverage
4. Sightseeing [domestic tour, etc.]
5. Shopping
6. Entertainment and leisure/sport activities
7. Medical care
8. Other expenses [convention fee, etc.]
Total
Part 3: Personal Data
1. Gender
[1] Male [2] Female
2. Age .............................year old
3. Occupation [1] Professionals [2] Administrative and Managerial
[3] Government and Military Personal [4] Clerical, Salesmen and Commercial Personal
[5] Housewife or Unpaid Family Workers [6] Student and Children
[7] Labourer [8] Agricultural worker
[9] Retired and Unemployed [10] Others [Please Specify] ………………………
4. For statistical records, we would like to know your personal income before taxes:
Currency ………………….…Amount………….…………….. [ ] per month [ ] per year
Or please specify annual personal income before taxes
264
[1] Less than US$ 20,000 [2] US$ 20,000-39,999 [3] US$ 40,000-59,999
[4] US$ 60,000-79,999 [5] US$ 80,000 and above
5. Which of the following statements best describes your current trip to Thailand?
[1] Medical treatment was the main purpose of this visit to Thailand.
[2] Medical treatment was only one of the reasons for this visit to Thailand.
[3] You planned this visit to Thailand before you thought of getting medical treatment
here.
6. If you had not needed medical treatment, do you think you would have…
[1] Definitely visited Thailand this year
[2] Probably visited Thailand this year
[3] Probably not visited Thailand this year
[4] Definitely not visited Thailand this year
********************Thank you very much********************
265
2. Questionnaire in Arabic language
2011استبيان إلجراء دراسة استقصائية عن نفقات السياحة الطبية لعام
: بيانات عن نفقات السفرالجزء األول ما اسم البلد الذي تقطنه؟ ......................................................................... .1
؟ الطبية الرعايةھل قمت بزيارة تايالند في السابق لتلقي .2 مرات 3] أكثر من 3[ ] مرة واحدة أو مرتان في السابق2[ ] أبداً 1[
..................... يوم.تايالندعدد األيام التي قضيتھا في .3
............................. يوم (للمرضى الداخليين فقط)المستشفىعدد األيام التي قضيتھا في .4
؟ (أي حزمة تتضمن ما ال يقل عن تكلفة الخدمة الطبية، وتذاكر السفر جواً حزمة من الخدمات الطبيةفيداً من ھل أتيت إلى تايالند مست .5 واإلقامة المدفوعة مسبقا قبل الرحيل)
] نعم1[ (إذا كان الجواب ال، يرجى االنتقال إلى السؤال السابع)] ال، لقد نظمت ھذه الرحلة بنفسي 2[
(اذكر العملة)ذه الحزمة من الخدمات الطبية (لشخص واحد فقط)؟ ................. كم دفعت ثمن ھ .6
يرجى مراجعة البنود المتضمنة في حزمة الخدمات الطبية ثمن تذكرة الطيران الجوي الدولي أو الباص )1
التنقل )2
التكلفة الطبية )3
اإلقامات )4
الطعام والشراب )5
زيارة المواقع السياحية )6
الخدمات الطبية )7
غير ذلك (حددھا)........................ )8
ما اسم شركة الطيران التي سافرت معھا من وإلى تايالند وما ھو المبلغ الذي دفعته لقاء تذكرة السفر بالطائرة (لشخص واحد)؟ .7
(اذكر العملة) ، ثمن تذكرة السفر .......................إلى تايالند .1
شركة طيران أخرى )2 ) الخطوط الجوية التايالندية1 (اذكر العملة) ، ثمن تذكرة السفر .......................من تايالند .2
سة الصحة الدولية من وزارة الصحة العامة برنامج سيا 2011يقوم بإجراء الدراسة اإلستقصائية التالية عن النفقات السياحة الطبية لعام د. التايالندية. وتتشكل الدراسة اإلستقصائية من أسئلة معظمھا عن نفقات السفر الخاصة بك في تايالند، وقد يحتاج إكماله بعض الوقت والجھ
احة العامة في تايالند باإلضافة للسياحة الطبية. كما وستساعدنا مشاركتك في ھذه الدراسة اإلستقصائية على التخطيط من أجل تحسين السي وسيتم التعامل مع إجاباتك بسرية تامة وألغراض الدراسة فقط.
شكراً
266
) شركة طيران أخرى2 الخطوط الجوية التايالندية 8
؟ الرجاء التأكد من ذكر جميع طرق الدفع (نقداً، وبطاقات االئتمان، أثناء زيارتك لتايالندماھو مجموع ما صرفته على كل من اآلتي .8إذا كنت مستفيداً من حزمة من الخدمات الطبية، تأكد من عدم شمول سعر الرحلة المنظمة التي اشتريتھا ت السفر، الخ). وشيكا
ضمن ھذا المبلغ.
أنواع النفقات المجموع (أذكر العملة)
خ)ال المحلية،التذكرة أجرة من( المحلية التنقالت
)المستشفى غرفة خدماتال تشمل ( اإلقامة
عمة وأشربةأط
)الخ محلية، سياحة( المدينة معالم شاھدةم
التسوق
الرياضيةو الترفيھية واألنشطة الترفيه
)المستشفى غرفة خدماتأشمل ( الطبية الرعاية
)إلخ المؤتمر، رسوم( أخرى نفقات
المجموع
: بيانات عن نفقات سفر مرافقيك/ أقربائكالجزء الثاني فقيك أو أقربائك الذين أتوا معك إلى ھذه الرحلة؟ .............................. شخص ما ھو عدد مرا .9
؟ الرجاء التأكد من ذكر جميع طرق الدفع خالل ھذه الزيارة لتايالندماھو مجموع ما صرفه مرافقوك أو أقرباؤك على كل من اآلتي .10 (نقداً، وبطاقات االئتمان، وشيكات السفر، الخ).
أنواع النفقات المجموع (أذكر العملة) د التالي من األشخاصنفقات العد
خ)ال المحلية،التذكرة أجرة من( المحلية التنقالت
اإلقامة
أطعمة وأشربة
)الخ محلية، سياحة( المدينة معالم شاھدةم
التسوق
الرياضيةو الترفيھية واألنشطة الترفيه
الطبية الرعاية
)إلخ المؤتمر، رسوم( أخرى نفقات
المجموع
267
: المعلومات الشخصيةالجزء الثالث الجنس .1
] أنثى2[ ] ذكر 1[
2. ً السن ............................. عاما
المھنة .3
صاحب مھنة حرفية )1
إداري أو تنظيمي )2
موظف حكومي أو عسكري )3
موظف سجالت، أو بائع أو تاجر )4
أو عامل في األسرة دون أجر ربة منزل )5
طالب أو طفل )6
عامل يدوي )7
عامل زراعي )8
متقاعد أو عاطل عن العمل )9
غير ذلك (يرجى التحديد)........................... )10
لغاية السجالت اإلحصائية، نود معرفة دخلك الشخصي قبل خصم الضرائب: .4
.......... [ ] في الشھر [ ] في السنةالعملة........................ المبلغ...................
أو يرجى تحديد الدخل الشخصي السنوي قبل خصم الضرائب: دوالر أمريكي 20000أقل من )1
دوالر أمريكي 39999 - 20000 )2
دوالر أمريكي 59999 - 40000 )3
دوالر أمريكي 79999 - 60000 )4
دوالر أمريكي وما فوق 80000 )5
الحالية لتايالند؟أي من اآلتي األدق في وصف رحلتك .5
العالج الطبي ھو السبب الرئيسي لزيارتي لتايالند )1
العالج الطبي ھو فقط أحد أسباب زيارتي لتايالند )2
قررت زيارة تايالند قبل التفكير بأخذ العالج ھنا )3
لعالج طبي، ھل تعتتقد بأنك كنت ستفعل التالي... لم تحتجإن .6 مؤكد.] تقوم بزيارة تايالند ھذا العام بشكل 1[ ] تقوم بزيارة تايالند ھذا العام على األرجح.2[ ] لن تقوم بزيارة تايالند ھذا العام على األرجح.3[ ] لن تقوم بزيارة تايالند ھذا العام بشكل مؤكد.4[
******************** شكراً جزيالً لك ********************
268
3. Questionnaire in Japanese language
2011 年医療観光経費に関する調査質問票
2011
年医療観光経費に関するこの調査は、タイ国保健省の国際医療プログラムの管理の下に行われるもので、大部分がタイで
の旅行費用に対する質問です。質問票への記入にご協力をお願いします。調査への皆様のご協力をタイの観光及び医療ツ
ーリズム産業の改善に反映させて頂きます。また、回答は調査のためのみに使用し、極秘とさせていただきます。
ありがとうございます。
Part 1: 旅行費用について 1. どちらの国にお住まいですか? ……………………………………………………..………..
2. これまでに治療目的でタイにいらっしゃった事はありますか ? [1] 一度もない [2] 1~2度ある [3] 3回以上
3. タイには何日くらいご滞在ですか …………………日間
4. 何日間入院されましたか ...................................... 日間入院)入院期間のみ(
5. 医療観光パッケージ・ツアーで来タイされましたか ? [ 例:来タイ前、事前に医療費や航空運賃、宿泊費用を支払い済み ] [1] はい
[2] いいえ。ツアーではなく個人で来タイ [ いいえの方は No.7 の質問へ進んで下さい ]
6. 医療パッケージ費用として一人あたりいくら支払われましたか ? …………....... [通貨単位明記]
医療パッケージに含まれる費用に丸をつけて下さい。
7. ご来タイにはどちらの航空会社を利用され、一人あたりいくら支払われましたか ?
7.1 来タイ航空運賃 ………….……………… [通貨単位明記]
[1] タイ航空 [2] その他航空会社
7.2 帰国航空運賃 ………….……………… [通貨単位明記]
[1] タイ航空 [2] その他航空会社
[1] 航空運賃 [2] 移動費用
[3] 治療費用 [4] 宿泊費用
[5] 飲食費用 [6] 観光費用
[7] 医療サービス費用 [8] その他 [ 詳しく ] …………….............
269
8. 今回のタイ訪問・滞在費用はおいくらでしたか?すべての支払方法)現金、クレジットカード、トラベラーズチェック他(を
含めた金額をお知らせ下さい。医療パッケージツアーでいらした方は、事前にお支払いになったパッケージツアー料金
は含めないでお答え下さい。
支出の種類 合計金額
[通貨単位明記]
1. タイ国内の交通費]国内線費用等[
2. 宿泊費]入院部屋代をのぞく[
3. 飲食費
4. 観光費用]国内観光ツアーなど[
5. 買い物
6. 娯楽、レジャー、スポーツなど
7. 医療]入院部屋代も含む[
8. その他支出]会議の費用など[
合計
Part 2: あなたの同伴者/親族の旅行費用について
9. 今回、何人の同伴者/親族といらっしゃいましたか ? .............................. 人
10. 今回の同伴者/親族のタイ訪問・滞在費用おいくらでしたか?すべての支払方法)現金、クレジットカード、トラベラーズ
チェック他(を含めた金額をお知らせ下さい。
支出の種類 合計金額
[通貨単位明記]
利用者の人数
]人[
1. タイ国内の交通費]国内線費用等[
2. 宿泊費]入院部屋代をのぞく[
3. 飲食費
4. 観光費用]国内観光ツアーなど[
5. 買い物
6. 娯楽、レジャー、スポーツなど
7. 医療]入院部屋代も含む[
8. その他支出]会議の費用など[
合計
270
Part 3: 個人情報
1. 性別
[1] 男性 [2] 女性
2. 年齢............................. 歳
3. 職業 [1] 専門職 [2] 管理職
[3] 政府・軍関係者 [4] 事務、営業、販売関係
[5] 主婦、家事手伝い [6] 学生、子供
[7] 肉体労働者 [8] 農業
[9] 引退、無職 [10] その他 [詳細] ………………………
4. 統計記録として、あなたの税引前個人所得をお知らせ下さい :
通貨 ………………….…金額………….…………….. [ ] 月収 [ ] 年収 もしくは下記から税引前個人年収をお知らせ下さい。
[1] 2 万ドル)約 160 万円(以下 [2] 2 万ドル)約 160 万円( -39,999 ドル)約 320 万円(
[3] 4 万ドル)約 320 万円( -59,999 ドル)約 480 万円(
[4] 6 万ドル)約 480 万円( -79,999 ドル)約 640 万円(
[5] 8 万ドル)約 640 万円(
5. 今回のタイ旅行について説明する場合、下記のどの表現に最も当てはまりますか。
[1] 主に医療サービスを受けることが目的のタイ旅行である。
[2] 医療サービスを受けることのみが目的のタイ旅行である。
[3] 医療サービスを受けることを考える前に計画を既に立てていたタイ旅行である。
6. 仮に医療サービスを受けることを必要としていなかった場合、あなたはどうしたと思われますか。
[1] 確実に今年タイを訪れていた。
[2] おそらく今年タイを訪れていた。
[3] おそらく今年タイを訪れていなかった。
[4] 確実に今年タイを訪れていなかった。
******************** ご協力、ありがとうございました。 ********************
271
Annex 4: Information sheet and consent form for interview (hospital executives and service providers)
1. For hospital executives
272
273
274
2. For service providers
275
276
277
278
Annex 5: Semi-structured questions for interview
1. Topic guide for hospital executive
Part 1: Questions on respondents’ background
1) What position are you holding in your hospital, and what is your role?
2) How long have you been in this hospital?
Part 2: Questions on resource management and resource allocation
1) Are medical tourists treated differently from domestic patients?
2) Are medical tourists used to fill up spare capacity or compete with domestic
patients?
3) Does hospital expand to build new capacity for medical tourist? And where
will extra resources come from?
4) If hospital has limited resources, for example only one bed, who would get it
between medical tourist and domestic patient?
279
2. Topic guide for service provider
Part 1: Questions on respondents’ background
1) What position are you holding in your hospital, and what is your role?
2) How long have you been in this hospital?
Part 2: Questions on variation of services
1) Are medical tourists treated differently from Thai patients?
2) If yes, in what kind of hospital services they differ and how do you think they
differ?
3) What do you think about international patients coming for medical services in
Thailand? And why do they come?
4) What do you get from serving medical tourists?
4.1) Encouraging your further specialty training
4.2) Capacity building on your medical2nursiing skill
4.2) Capacity building on your English/other languages skill
4.4) Career advancement for working abroad in the future
4.5) Pleasing remuneration
280
Annex 6: List of interview participants
No Name Position Hospital Interview
date Code
1 Dr Montri Luxuwong Vice director Bumrungrad International
Hospital
31 August H1E1
2 Mr. Kenneth Mays Marketing Director 25 July H1E2
3 Mrs. Artirat Charukitpipat Chief Human Resource Officer
14 August H1E3
4 Ms. Ansuree Suwansura Nurse 27 July H1N1
5 Ms. Sukanya Kon-on Nurse 31 July H1N2
6 Dr Kritawit Lertusahakul Director Bangkok Hospital
21 June H2E1
7 Dr Trin Jarumilind Medical Director 21 June H2E2
8 Mrs. Sumalee Promburi Human Resource Director
21 June H2E3
9 Ms. Pojana Suksamanwong, Marketing Director 8 August H2E4
10 Dr Nattanun Prasassarakich Doctor 21 June H2M1
11 Dr Laksamee Chanvej Doctor 8 August H2M2
12 Dr Supreecha Kapiya Doctor 9 August H2M3
13 Dr Sithiphol Chinnapongse Doctor 15 August H2M4
14 Ms. Prapaporn Nichangtong Nurse 14 August H2N1
15 Ms. Jitraporn Khankum Nurse 14 August H2N2
16 Ms. Weranuch Wiboonpan Nurse 15 August H2N3
17 Mrs. Pannee Songsai Nurse 15 August H2N4
18 Mrs. Poranee Pongnoppakun Nurse 21 June H2N5
19 Dr Pichit Kangwolkij Director Bangkok Pattaya Hospital
19 June H3E1
20 Dr Supakorn Winwak Deputy Director 19 June H3E2
21 Mrs. Nirachorn Sirisampan Marketing director for Foreign Affairs
19 June H3E3
22 Ms. Datchaneeporn Pantaprom Human Resource Director
20 June H3E4
23 Dr Woratorn Munintorn Doctor 19 June H3M1
24 Dr Athakorn Kirakul Doctor 19 June H3M2
25 Dr Niyom Pisitpipattana Doctor 19 June H3M3
26 Dr Attaporn Suwannik Doctor 20 June H3M4
27 Dr Tassanee Lertutsahakul Doctor 20 June H3M5
28 Ms. Wachara Kaopong Nurse 20 June H3N1
29 Ms. Lissara Dungpetch Nurse 20 June H3N2
30 Ms. Saovanee Reungsri Nurse 20 June H3N3
31 Ms. Panee Pasuk Nurse 20 June H3N4
32 Ms. Sirarom Janechotsuwan Nurse 20 June H3N5
33 Dr Narongrit Havarngsi Director Bangkok Phuket
Hospital
13 July H4E1
34 Dr Bodin La-ied Deputy Director 13 July H4E2
35 Mr. Charnchai Panya Marketing director for Foreign Affairs
12 July H4E3
281
No Name Position Hospital Interview date
Code
36 Mr. Chaowalit Laoprasertsiri Human Resource Manager
Bangkok Phuket
Hospital
12 July H4E4
37 Dr Piyapas Pichaichannarong Doctor 12 July H4M1
38 Dr Supachai Kerdsap Doctor 13 July H4M2
39 Dr Lalita Kongsiha Doctor 12 July H4M3
40 Mrs. Ratree Koythanakom Nurse 11 July H4N1
41 Mrs. Kattika Lakleam Nurse 11 July H4N2
42 Mrs. Pacharee Sungthong Nurse 12 July H4N3
43 Mrs. Somlak Samgpleng Nurse 12 July H4N4
282
Annex 7: Country comparison on characteristic of medical tourists
Country comparison on characteristic of medical tourists
For country selection in specific question 4, this study selected countries with the
largest number of medical tourists in each region in top-10 country. Five countries
were selected including UK from Europe, USA from North America, Australia from
Australia and Oceania, Myanmar form Southeast Asia and UAE from Middle East.
These five countries had a total of 44,284 medical tourists accounting for 42% of
total medical tourists (Table 8.1).
Table 8.1: Number of patients in five selected countries
Number of patients Total patients in
the region
% of total
number
United Kingdom 3,935 14,004 28.1
USA 7,854 9,481 82.8
Australia 3,359 3,949 85.1
Myanmar 7,569 14,730 51.4
U.A.E. 21,567 40,554 53.2
Total 44,284 104,830 42.2
In 2010, there were 44,284 medical tourists from five countries with separate
104,830 visits (Table 8.2). They accounted 42.2% of total medical tourist. Medical
tourists from UAE had the highest utilization rate, approximately 4.4 visits per
person per year while those from UK had the lowest rate, approximately 2.7 visits
per patient per year.
Table 8.2: Number of patients, visit and utilization rate of medical tourists in five countries
Number of patients Number of visit Utilization rate
United Kingdom 3,935 10,779 2.7
USA 7,854 24,262 3.1
Australia 3,359 10,136 3.0
Myanmar 7,569 32,940 4.4
U.A.E. 21,567 63,457 2.9
Total 44,284 141,574 3.2
283
1. Gender and age
Men dominated most countries except Myanmar (Table 8.3). The largest age group in
most countries except UAE was age between 45-54 year while one in UAE was age
between 25-34 year (Table 8.4). Myanmar had the biggest group in age more than 65
compared to other countries. Patients from Myanmar had the highest average age,
approximately 46.65 year while those from UAE had the lowest, approximately
37.42 year (Table 8.5).
Table 8.3: Gender comparison of medical tourists among five countries
Country
United
Kingdom
USA Australia Myanmar U.A.E.
Male Count 2,702 5,135 1,727 3,360 12,230
% 68.7% 65.4% 51.4% 44.4% 56.7%
Female Count 1,231 2,717 1,632 4,208 9,337
% 31.3% 34.6% 48.6% 55.6% 43.3%
Total Count 3,933 7,852 3,359 7,568 21,567
% 100.0% 100.0% 100.0% 100.0% 100.0%
Table 8.4: Age distribution among five countries
Country
United
Kingdom
USA Australia Myanmar U.A.E.
Less than 25 Count 321 847 375 754 4561
% 8.2% 10.8% 11.2% 10.0% 21.2%
25-34 Count 498 1034 607 761 5509
% 12.7% 13.2% 18.1% 10.1% 25.6%
35-44 Count 819 1372 746 1687 4367
% 20.8% 17.5% 22.2% 22.3% 20.3%
45-54 Count 1015 1857 779 1939 3353
% 25.8% 23.6% 23.2% 25.6% 15.6%
55-64 Count 831 1880 613 1411 2265
% 21.1% 23.9% 18.2% 18.6% 10.5%
More than 65 Count 450 864 239 1017 1504
% 11.4% 11.0% 7.1% 13.4% 7.0%
Total Count 3934 7854 3359 7569 21559
% 100.0% 100.0% 100.0% 100.0% 100.0%
284
Table 8.5: Average age of medical tourists among five countries
Gender Mean N Std. Deviation Minimum Maximum Median
United Kingdom 46.52 3,932 15.82 0 91 48.00
USA 45.68 7,852 17.23 0 95 48.00
Australia 43.42 3,359 14.98 0 88 44.00
Myanmar 46.65 7,568 16.52 0 95 47.00
UAE 37.42 21,559 17.43 0 106 36.00
Statistical analysis
From table 8.1, Pearson Chi-square test is employed to prove whether there is any
difference in gender distribution among medical tourists in five countries. It is found
that there is statistically difference in gender (p value < 0.0001) among medical
tourists in five countries.
Analysis of Variance (ANOVA) test is also employed to prove whether there is any
difference in an average age among medical tourists in five countries. The null
hypothesis is an average age of medical tourists in all countries are the same. It is
found that there is statistically difference (p value < 0.0001) in average age among
five countries. Hence, the average ages of medical tourist in five countries are not
the same. The statistical analysis also finds that an average age of medical tourist
from UK is very similar to one of those from Myanmar (p value > 0.99).
3. Disease pattern
3.1 Male comparison
In contrast to region comparison, male patients of five countries, being from different
regions including long-haul and within regions, had comparatively similar disease
pattern (Table 8.6). Health check-up, disease of digestive system, disease of
circulatory system and disease of musculo-skeleton were common problems in all
countries. Health check-up including medical consultation and treatment follow up
were the most common, ranging from 28% in Myanmar to 41% in Australia. Disease
of skin and sub-cutaneous tissue, related to cosmetic problems, were also common in
male patients from USA and Australia.
285
Table 8.6: Disease pattern in male medical tourists among five countries
Male diagnosis Country Total
United
Kingdom
USA Australia Myanmar U.A.E.
Health examination, medical
consultation and treatment follow-up
Count 2,690 5,720 1,668 3,399 11,685 25,162
% 40.5% 39.7% 41.0% 27.8% 38.0% 37.0%
Diseases of the digestive system Count 815 1,631 597 939 2,421 6,403
% 12.3% 11.3% 14.7% 7.7% 7.9% 9.4%
Diseases of the circulatory system Count 420 887 201 1,398 1,885 4,791
% 6.3% 6.2% 4.9% 11.5% 6.1% 7.0%
Diseases of the musculo-skeletal
system and connective tissue
Count 398 926 208 426 2,098 4,056
% 6.0% 6.4% 5.1% 3.5% 6.8% 6.0%
Diseases of the genito-urinary system Count 329 643 181 636 1,971 3,760
% 5.0% 4.5% 4.4% 5.2% 6.4% 5.5%
Endocrine, nutritional and metabolic
diseases
Count 224 540 155 907 1,837 3,663
% 3.4% 3.7% 3.8% 7.4% 6.0% 5.4%
Diseases of the skin and subcutaneous
tissue
Count 312 798 249 270 1,727 3,356
% 4.7% 5.5% 6.1% 2.2% 5.6% 4.9%
Neoplasms Count 264 545 124 1,410 918 3,261
% 4.0% 3.8% 3.0% 11.6% 3.0% 4.8%
Diseases of the eye and adnexa Count 244 577 177 359 1,246 2,603
% 3.7% 4.0% 4.3% 2.9% 4.1% 3.8%
Infectious and parasitic diseases Count 216 501 130 1,206 524 2,577
% 3.3% 3.5% 3.2% 9.9% 1.7% 3.8%
Diseases of the respiratory system Count 148 354 110 322 1,159 2,093
% 2.2% 2.5% 2.7% 2.6% 3.8% 3.1%
Symptoms, signs and laboratory
findings, not elsewhere classified
Count 107 236 61 288 787 1,479
% 1.6% 1.6% 1.5% 2.4% 2.6% 2.2%
Diseases of the nervous system Count 128 321 35 214 778 1,476
% 1.9% 2.2% .9% 1.8% 2.5% 2.2%
Mental and behavioural disorders Count 156 361 61 162 605 1,345
% 2.4% 2.5% 1.5% 1.3% 2.0% 2.0%
Diseases of the ear and mastoid
process
Count 124 244 72 107 549 1,096
% 1.9% 1.7% 1.8% .9% 1.8% 1.6%
Diseases of the blood and the immune
mechanism
Count 31 69 9 93 229 431
% .5% .5% .2% .8% .7% .6%
Congenital malformations, and
chromosomal abnormalities
Count 10 23 19 45 214 311
% .2% .2% .5% .4% .7% .5%
Injury, poisoning and certain other
consequences of external causes
Count 11 15 8 9 74 117
% .2% .1% .2% .1% .2% .2%
Certain conditions originating in the
perinatal period
Count 0 11 0 5 19 35
% .0% .1% .0% .0% .1% .1%
External causes of morbidity and
mortality
Count 7 4 4 3 14 32
% .1% .0% .1% .0% .0% .0%
Pregnancy, childbirth and the
puerperium
Count 2 4 0 8 11 25
% .0% .0% .0% .1% .0% .0%
Total Count 6,636 14,410 4,069 12,206 30,751 68,072
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
286
From table 8.6, Pearson’s Chi-square test is employed to prove whether there is any
difference on disease pattern among male medical tourists from five countries. It is
found that there is statistically difference in disease pattern (p value < 0.0001) among
male medical tourists from five countries.
3.2 Female comparison
Disease pattern in female patients from UK, USA and Australia was comparatively
similar while one in those from Myanmar and UAE was quite related (Table 8.7).
Health check-up, disease of genito-urinary system, disease of digestive system and
disease of skin were common in female patients form UK, USA and Australia. Health
check-up, disease of genito-urinary system and metabolic diseases were common in
those from Myanmar and UAE.
In conclusion, comparing disease pattern in term of country, male patients had quite
similar disease pattern among countries from long-haul and within regions. In
contrast, in female comparison, there was different disease pattern among countries
from long-haul and within regions.
287
Table 8.7: Disease pattern in male medical tourists among five countries
Female diagnosis Country Total
United
Kingdom
USA Australia Myanmar U.A.E.
Health examination, medical
consultation and treatment follow-up
Count 1,744 4,203 2,965 5,784 11,958 26,654
% 52.5% 51.2% 63.9% 36.5% 42.6% 44.3%
Diseases of the genito-urinary system Count 258 519 203 1,336 2,400 4,716
% 7.8% 6.3% 4.4% 8.4% 8.5% 7.8%
Neoplasms Count 108 339 54 2,044 1,467 4,012
% 3.2% 4.1% 1.2% 12.9% 5.2% 6.7%
Diseases of the digestive system Count 248 719 409 766 1,786 3,928
% 7.5% 8.8% 8.8% 4.8% 6.4% 6.5%
Diseases of the musculo-skeletal system
and connective tissue
Count 130 335 86 766 2,189 3,506
% 3.9% 4.1% 1.9% 4.8% 7.8% 5.8%
Endocrine, nutritional and metabolic
diseases
Count 100 332 141 1,220 1,662 3,455
% 3.0% 4.0% 3.0% 7.7% 5.9% 5.7%
Diseases of the skin and subcutaneous
tissue
Count 138 450 263 325 1,749 2,925
% 4.2% 5.5% 5.7% 2.1% 6.2% 4.9%
Diseases of the circulatory system Count 150 200 64 978 934 2,326
% 4.5% 2.4% 1.4% 6.2% 3.3% 3.9%
Diseases of the eye and adnexa Count 113 280 132 366 774 1,665
% 3.4% 3.4% 2.8% 2.3% 2.8% 2.8%
Infectious and parasitic diseases Count 58 128 41 971 344 1,542
% 1.7% 1.6% .9% 6.1% 1.2% 2.6%
Diseases of the respiratory system Count 61 156 62 220 606 1,105
% 1.8% 1.9% 1.3% 1.4% 2.2% 1.8%
Symptoms, signs and abnormal clinical
and laboratory findings,
Count 44 99 21 322 531 1,017
% 1.3% 1.2% .5% 2.0% 1.9% 1.7%
Diseases of the nervous system Count 30 86 15 196 468 795
% .9% 1.0% .3% 1.2% 1.7% 1.3%
Diseases of the blood and blood-forming
organs and the immune mechanism
Count 9 33 13 178 439 672
% .3% .4% .3% 1.1% 1.6% 1.1%
Diseases of the ear and mastoid process Count 35 80 35 122 311 583
% 1.1% 1.0% .8% .8% 1.1% 1.0%
Congenital malformations, deformations
and chromosomal abnormalities
Count 17 36 44 72 218 387
% .5% .4% .9% .5% .8% .6%
Mental and behavioral disorders Count 34 81 27 93 133 368
% 1.0% 1.0% .6% .6% .5% .6%
Pregnancy, childbirth and the
puerperium
Count 39 119 25 49 98 330
% 1.2% 1.5% .5% .3% .3% .5%
Injury, poisoning and certain other
consequences of external causes
Count 6 4 27 15 17 69
% .2% .0% .6% .1% .1% .1%
External causes of morbidity and
mortality
Count 2 3 15 4 7 31
% .1% .0% .3% .0% .0% .1%
Certain conditions originating in the
perinatal period
Count 0 2 0 10 4 16
% .0% .0% .0% .1% .0% .0%
Total Count 3,324 8,204 4,642 15,837 28,095 60,102
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
288
From table 8.7, Pearson Chi-square test is employed to prove whether there is any
difference on disease pattern among female medical tourists from five countries. It is
found that there is statistically difference in disease pattern (p value < 0.0001) among
female medical tourists from five countries.
4. Type of procedure
In 2010, 5,824 procedures were conducted in medical tourists from five countries,
accounting for 47% of total procedures in all medical tourists (Table 8.8). Australian
medical tourists had the highest operation rate while those from UAE had the lowest
rate. In term of gender, male UK medical tourists tended to have more operations
than female ones. On the contrary, female Australian medical tourists had much more
operations than men Australian.
Table 8.8: Number of procedures in medical tourists in five countries in 2010
Male % within
country
Female % within
country
Total %
between
countries
Rate
(Procedures/
100 patients)
United Kingdom 277 59.3 190 40.7 467 8.0 11.87
USA 505 49.5 516 50.5 1,021 17.5 13.00
Australia 221 18.2 990 81.8 1,211 20.8 36.05
Myanmar 747 52.6 673 47.4 1,420 24.4 18.76
U.A.E. 900 52.8 805 47.2 1,705 29.3 7.91
Total 2,650 45.5 3,174 54.5 5,824 100.0 13.15
4.1 Male comparison
Pattern of procedure in male medical tourists compared among countries was similar
to those in region comparison. Countries from long-haul region, UK, USA and
Australia, had comparatively similar pattern while countries from within regions,
Myanmar and UAE, also had similar pattern (Table 8.9). Heart-related procedures
and procedures on digestive system were two most common procedures in male
patients from Myanmar and UAE. Cosmetic procedures, heart-related and
orthopaedic procedures were common operations in male patients from UK, USA
and Australia.
289
Table 8.9: Procedures in male medical tourists in five countries
Male procedure Country
United
Kingdom
USA Australia Myanmar U.A.E.
Miscellaneous and therapeutic procedures
(mostly cardiac catheter insertion)
Count 36 68 24 145 132
% 13.0% 13.5% 10.9% 19.4% 14.7%
Digestive system Count 46 45 23 113 144
% 16.6% 8.9% 10.4% 15.1% 16.0%
Musculo-skeleton system Count 55 111 24 36 85
% 19.9% 22.0% 10.9% 4.8% 9.4%
Procedures and interventions, not classified
elsewhere (mostly angio-cardiogram)
Count 16 19 8 120 132
% 5.8% 3.8% 3.6% 16.1% 14.7%
Cardiovascular system Count 19 34 5 136 95
% 6.9% 6.7% 2.3% 18.2% 10.6%
Integumentary system (mostly cosmetic
surgery)
Count 24 93 61 9 42
% 8.7% 18.4% 27.6% 1.2% 4.7%
Eyes Count 29 45 29 21 32
% 10.5% 8.9% 13.1% 2.8% 3.6%
Nose, mouth and pharynx Count 8 20 24 26 63
% 2.9% 4.0% 10.9% 3.5% 7.0%
Male genital organs Count 12 33 12 17 48
% 4.3% 6.5% 5.4% 2.3% 5.3%
Urinary system Count 10 9 2 37 53
% 3.6% 1.8% .9% 5.0% 5.9%
Respiratory system Count 3 8 2 32 32
% 1.1% 1.6% .9% 4.3% 3.6%
Nervous system Count 11 10 3 30 21
% 4.0% 2.0% 1.4% 4.0% 2.3%
Haemic and lymphatic system Count 1 3 0 13 8
% .4% .6% .0% 1.7% .9%
Ear Count 1 0 3 6 7
% .4% .0% 1.4% .8% .8%
Endocrine system Count 3 1 0 4 6
% 1.1% .2% .0% .5% .7%
Other diagnosis and therapeutic procedures Count 3 6 1 1 0
% 1.1% 1.2% .5% .1% .0%
Female genital organ Count 0 0 0 1 0
% .0% .0% .0% .1% .0%
Total Count 277 505 221 747 900
% 100.0% 100.0% 100.0% 100.0% 100.0%
From table 8.9, Pearson’s Chi-square test was employed to find out whether there
was any difference in patterns of procedure among male medical tourists from five
countries. Statistical difference in procedure pattern (p value < 0.0001) was found.
290
4.2 Female comparison
Pattern of procedure in female medical tourists compared among countries was
similar to those in region comparison. Pattern in countries from long-haul regions
including UK, USA and Australia were moderately alike while pattern of those from
within region were also similar (Table 8.10). Cosmetic-related procedures dominated
female patients from UK, USA and Australia. Most of procedures in female patients
from Australia – approximately 80%, were cosmetic operations. Female genital
organs, digestive and heart-related procedures were the main operations in those
from Myanmar and UAE.
In summary, similar to region comparison, type of procedures in medical tourists
from UK, USA and Australia, being from long-haul regions, are similar pattern while
one in those from Myanmar and UAE, being from within region, are also similar.
291
Table 8.10: Procedures in female medical tourists in five countries
Female procedure Country
United
Kingdom
USA Australia Myanmar U.A.E.
Integumentary system (mostly cosmetic
surgery)
Count 97 245 794 42 80
% 51.1% 47.5% 80.2% 6.2% 9.9%
Female genital organ Count 16 56 18 121 171
% 8.4% 10.9% 1.8% 18.0% 21.2%
Digestive system Count 5 32 9 129 148
% 2.6% 6.2% .9% 19.2% 18.4%
Eyes Count 26 62 114 21 14
% 13.7% 12.0% 11.5% 3.1% 1.7%
Miscellaneous and therapeutic procedures
(mostly cardiac catheter insertion)
Count 5 15 7 102 91
% 2.6% 2.9% .7% 15.2% 11.3%
Musculoskeleton system Count 10 27 6 60 75
% 5.3% 5.2% .6% 8.9% 9.3%
Cardiovascular system Count 2 1 3 65 47
% 1.1% .2% .3% 9.7% 5.8%
Nose, mouth and pharynx Count 10 15 22 9 28
% 5.3% 2.9% 2.2% 1.3% 3.5%
Procedures and interventions, not elsewhere
classified (mostly angio-cardiogram)
Count 3 3 3 22 39
% 1.6% .6% .3% 3.3% 4.8%
Respiratory system Count 0 7 5 31 22
% .0% 1.4% .5% 4.6% 2.7%
Endocrine system Count 6 18 8 15 14
% 3.2% 3.5% .8% 2.2% 1.7%
Urinary system Count 3 4 0 23 24
% 1.6% .8% .0% 3.4% 3.0%
Nervous system Count 2 2 1 12 26
% 1.1% .4% .1% 1.8% 3.2%
Obstetrics Count 4 24 0 9 4
% 2.1% 4.7% .0% 1.3% .5%
Haemic and lymphatic system Count 1 3 0 10 16
% .5% .6% .0% 1.5% 2.0%
Ear Count 0 2 0 2 6
% .0% .4% .0% .3% .7%
Total Count 190 516 990 673 805
% 100.0% 100.0% 100.0% 100.0% 100.0%
From table 8.10, Pearson Chi-square test is employed to prove whether there is any
difference on procedure pattern among female medical tourists from five countries. It
is found that there is statistically difference in procedure pattern (p value < 0.0001)
among female medical tourists from five countries.
292
5. Length of stay
Similar to regional comparison, medical tourists from UAE tended to have the
longest duration of stay in hospitals while those from Australia had the shortest one.
Most patients from all countries stayed in hospital between 1-3 days (Table 8.11).
UAE had the largest group of patients staying more than 30 days, accounting for
8.2%, compared to other countries. Patients from UAE have the longest period with
almost 10 days per patients and those from Australia have the shortest one with only
2.3 days per patients (Table 8.12).
Table 8.11: Length of stay of medical tourists from five countries
Country
United
Kingdom
USA Australia Myanmar U.A.E.
1-3 days Count 195 487 683 478 587
% 70.9% 74.4% 88.2% 52.2% 60.6%
4-7 days Count 44 106 64 212 160
% 16.0% 16.2% 8.3% 23.2% 16.5%
8-14 days Count 22 33 14 136 95
% 8.0% 5.0% 1.8% 14.9% 9.8%
15-30 days Count 9 17 12 66 47
% 3.3% 2.6% 1.6% 7.2% 4.9%
More than 30 days Count 5 12 1 23 79
% 1.8% 1.8% .1% 2.5% 8.2%
Total Count 275 655 774 915 968
% 100.0% 100.0% 100.0% 100.0% 100.0%
Table 8.12: Average length of stay of medical tourists from five countries
Mean N Std.
Deviation
Minimum Maximum Median
UK 4.29 275 6.68 1 51 2.00
USA 3.89 654 7.63 1 111 2.00
Australia 2.30 774 2.93 1 32 2.00
Myanmar 6.53 915 9.94 1 137 3.00
UAE 9.98 968 22.47 1 228 3.00
293
Statistical analysis
Analysis of Variance (ANOVA) test was employed to find out whether there was any
difference in the average length of stay among medical tourists from five countries.
The null hypothesis was that the average age of medical tourists from all countries
was the same. Statistically difference (p value < 0.0001) was found, thus, the average
length of stay in five countries is not the same.
6. Type of payment
Self-pay was the main payment method in patients from five countries (Table 8.13).
Corporate contract was the second most popular type of payment, however, with
relatively low percentages. Similar to the comparison among regions, private
insurance was the least popular mode for medical expenditure payment.
Table 8.13: Types of payment by medical tourists among five countries
Country
United
Kingdom
USA Australia Myanmar U.A.E.
Self -pay Count 8,689 18,873 7,044 27,443 55,942
% 88.5% 85.1% 87.1% 94.0% 95.4%
Insurance Count 393 1,376 231 147 23
% 4.0% 6.2% 2.9% .5% .0%
Corporate contract Count 740 1,939 812 1,592 2,645
% 7.5% 8.7% 10.0% 5.5% 4.5%
Total Count 9,822 22,188 8,087 29,182 58,610
% 100.0% 100.0% 100.0% 100.0% 100.0%
Statistical analysis
From table 4.46, Pearson’s Chi-square test is employed to prove whether there is any
difference in type of payment among medical tourists in five countries. Statistical
difference in types of payment (p value < 0.0001) was found.